As I previously blogged, the Catholic hospital brand is no longer desirable in the marketplace for mergers and acquisitions of healthcare entities.

This realization led Catholic Healthcare West, the nation’s fifth largest healthcare conglomerate, to give up its status as a ministry of the Catholic Church. In doing so the corporation exempted itself from obedience to the Ethical and Religious Directives for Catholic Healthcare (ERDs) and released its secular hospitals from control by their local bishops. Local bishops and the ERDs still define permitted services in its 25 Catholic hospitals.

The corporation changed its name to Dignity Health, revamped its board of directors and replaced the ERDs with a “Statement of Common Values” to set the ethical framework and define permissible care. Though not entirely secular (the Values Statement still refers to employees as “the hands and heart of the ministry), Dignity is clearly not Catholic when it comes to reproductive health. The Common Values statement precludes abortion and in vitro fertilization, but is silent on tubal ligation and vasectomy.

When it comes to services at the end of life, Dignity does little to release patients from the chains of Catholic doctrine. The Statement pays lip service to patients’ rights to make medical decisions, execute advance directives and name surrogate-decision makers. Then it goes on to address the crux of the matter — withholding or withdrawing life-sustaining treatment, and allowing the legal choice of aid in dying.

At first glance Dignity Health’s policy on life-sustaining treatment may seem balanced and patient-centered:

There is no obligation to begin or continue treatment, even life-sustaining treatment, if from the patient’s perspective it is an excessive burden or offers no reasonable hope of benefit. Death is a sacred part of life’s journey; we will intentionally neither hasten nor delay it.

Let’s put aside the obvious absurdity that a whole hospital system would vow not to intentionally delay death! That’s their primary job, no? And I trust if I arrived at a Dignity Health facility, injured and bleeding, they would do everything in their power to delay my death!

It appears that in their haste to disavow any participation in an intended death, drafters of Common Values inadvertently applied the mantra of the Catholic hospice industry to an entire healthcare system, including emergency rooms and surgery suites. Perhaps they can fix that in the next edition.

Retaining Catholic Doctrine Around Intention

I have written at length about the Catholic Doctrine of Double Effect and the disservice it pays dying patients. It allows death to come only as an untended consequence of treatment to relieve pain and other symptoms and never as the intended purpose of an act or omission. Any act or omission intended to cause death is labeled “euthanasia” in the ERDs and strictly forbidden.

The ban on purposeful dying gags patients who might otherwise express a yearning to complete a prolonged dying process. It tempts doctors to hold back on opiates as pain and breathlessness escalate during active dying, because they fear being accused of intending the impending death and practicing euthanasia.

A host of alternatives for peaceful dying are considered ethical and legal in every state. They include discontinuation of treatments like renal dialysis, ventilation and feeding tubes, deactivation of implanted pacemakers and defibrillators, and provision of treatments like palliative sedation and drugs to prevent air hunger and ease the dying process during ventilator discontinuation.

Under Dignity Health’s restrictions regarding “intention” patients and their doctors are allowed these legal alternatives only if they disavow any purpose to abbreviate the period of suffering and advance the time of death. Patients must ask in code to be “relieved of the burden of cardiac pacing” instead of asking to stop the pacemaker so the heart will slow, because the patient wishes to die.

Test Case in Ashland, Oregon

Dignity Health’s expansion plans target Oregon and its first acquisition is the community hospital in the city of Ashland. Officials at Dignity and Ashland Community Hospital (ACH) are working out details of the acquisition, but the Ashland City Council must approve the deal, because it involves leasing public lands.

ACH CEO Mark Marchetti has said since ACH never provided aid in dying on its premises, its function in relation to the state’s Death with Dignity Act will not change. We’re not so sure, and believe the City Council and Ashland residents deserve some assurances.

It matters little whether hospitals allow patients to take life-ending medication on their premises, because people don’t choose to die in a hospital anyway. Wanting to die at home is one of the big motivators for people gaining eligibility for aid in dying in Oregon. But access does depend on a host of patient-provider interactions that precede a patient exercising their rights under the law. Catholic entities in Oregon forbid these interactions, and it’s important to ensure ACH will not start doing the same.

We have asked ACH officials to assure Ashland residents in writing that the institution resulting from negotiations between ACH and Dignity Health will:

1. Retain a neutral stance toward aid in dying and will not penalize, discharge or reduce services for patients who gain eligibility for aid in dying;
2. Do nothing to prevent, deter or punish employees who provide patients with information about accessing aid in dying under the Oregon Death with Dignity Act.
3. Permit its staff and contracted physicians to answer patients’ questions about aid in dying and refer requesting patients to knowledgeable and supportive resources to pursue their request;
4. Allow employed, contract physicians and physicians with hospital privileges to discuss aid in dying upon a patient’s request and fulfill duties such as medical history review, consultation and reporting required by the Death with Dignity Act on its hospital premises and medical offices.

This week, ACH responded positively — in writing — to our request for assurances. The Ashland City Council should put the ACH response on record and make their approval contingent on those promises. Only then can the residents of Ashland have confidence that Dignity Health’s involvement in their community will not deprive them of rights and privileges they have held for fifteen years.

But the medical establishment’s support for patient choice exists within a particular, and peculiar, bioethical framework. Doctors usually invoke the Catholic doctrine of double effect to explain how they can perform an act, such as administering sedatives and disconnecting a ventilator, knowing the two acts will cause the patient’s death. The doctrine holds that a person is not responsible for what they know will ensue as the product of their actions, so much as what they intend. In essence, “my intention was not to cause death, my intention was to ease suffering.”

A problem arises for palliative care physicians when people question their intention. Since it is impossible to prove a thought, doctors will always be vulnerable to accusations about intentions. This vulnerability is exploited when anti-choice advocates promote legislation that 1) raise the bar on what will pass for lawful practice and thought, 2) magnify penalties for those found guilty of forbidden thoughts and intentions and 3) encourage scrutiny and whistleblowing by onlookers and medical colleagues. And the medical lobby has done little to oppose these bills.

Recent events illustrate the danger.

Georgia HB 1114, passed last month to prohibit assisted suicide. Shaped by Georgia Right to Life and the Georgia Catholic Conference (thanked from the floor of the House) and with no visible objection from the physician community HB 1114 purports to outlaw suicide assistance. Here I would like to affirm my strong support for clear laws and harsh penalties for those who incite and abet suicide.

But a mere 19 of this bill’s 57 lines address actual criminal behavior.  The bill’s drafters wasted few words on perpetrators of violence, guns, nooses and other atrocities by which online predators and other malicious enablers encourage self-destructive impulses of the mentally ill. The heinous crime of inciting a despondent or disturbed person to kill themselves seems almost an afterthought in this bill.

The bulk of the bill — 37 lines — frets over patient decision-making and medical treatment in minute detail. It focuses on doctors more than the voyeurs and predators that endanger society. The new law repeatedly specifies that any withholding, withdrawing, prescribing, administering or dispensing must be solely intended and calculated to relieve symptoms and never to cause death. Some tried to allow treatment that “eases the dying process,” but the lawmakers deemed that language too permissive and generous.

Georgia lawmakers not only paste targets on healthcare professionals, they also armed those taking aim at forbidden intentions with the state’s RICO (Racketeer Influenced and Corrupt Organization) law. The heavy artillery of RICO magnifies the state’s policing authority, extends penalties, adds civil liability and enables prosecution of individuals only tangentially involved in the patient’s care.

A recent study showed onlookers and watchful colleagues already threaten palliative care physicians with accusations of murder and euthanasia. Over half of palliative physicians report they have endured such accusations at least once, some as often as 6 times, over the past 5 years. And in the bills they promote, anti-choice advocates enable these watchdogs.

Patients need more legislative vigilance on their behalf. Dying patients need a voice in our nation’s statehouses. Without one, the creation of thought crimes, threats of exorbitant punishment and hyper-vigilant whistle-blowers could stunt the future of palliative care.