End-of-Life Choice, Palliative Care and Counseling

Argentina’s senate votes for “dignified death” lawby Jay

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CBS News
May 10, 2012

Argentina’s senate on Wednesday overwhelmingly approved a “dignified death” law giving terminally ill patients and their families more power to make end-of-life decisions.

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The law passed by a vote of 55 to zero, with 17 senators declaring themselves absent. It passed the lower house last year.

Now Argentine families won’t have to struggle to find judges to order doctors to end life-support for people who are dying or in a permanent vegetative state. Getting such approval can be very difficult in many countries, particularly in Latin America, where opposition from the Roman Catholic church still runs strong.

“I think it’s very good,” said Angel Robles, a 71-year-old retired taxi driver with terminal esophageal cancer who entered a hospice last week. “If I’m OK, these are things that I have to decide. But if not, I have confidence in my daughter.”

The measure expressly forbids euthanasia – actions that provoke death – and instead focuses on the rights of patients and their families. It also absolves doctors of any legal responsibility when they follow the patient’s wishes.

The law applies to the terminally ill as well as patients suffering from irreversible and incurable illness or injury, and says they have the right to refuse surgical procedures, hydration and nutrition, reanimation and life-support systems. Rather than seek a court order, all they need do is prepare an advanced health-care directive and sign it before a notary, with two witnesses.

The ethical challenges surrounding end-of-life issues become more difficult when the patient can no longer speak for himself and has not prepared such a formal document. In these cases, the Argentine law empowers family members or legal representatives to make the decision on the patients’ behalf.

Some lawmakers expressed discomfort about withdrawing feeding tubes or life support to someone who can no longer communicate. Deputy Julian Obligo of the conservative PRO party pleaded with senators to eliminate this reference, alleging that it amounts to euthanasia by hastening death. And Sen. Sonia Escudero, a dissident member of the governing Peronist party, alleged that withdrawing nutrition and hydration could cause pain to a dying person.

Medical and bioethical experts say otherwise — that an abundance of scientific evidence shows that dying people naturally stop eating and drinking for a reason — their bodies are shutting down — and that force-feeding them at that point actually causes pain. In contrast, without food and drink, the metabolism produces substances that actually produce feelings of euphoria.

By withdrawing feeding tubes, “you make their time more comfortable, not less, when they are near death,” said Dan Brock, who teaches medical ethics at Harvard University in Cambridge, Mass. “All the evidence suggests they are not suffering.”

“This was highly controversial 20 years ago when it began to be debated in the United States, and the Catholic Church still officially opposes it, but here anyway it’s now a matter of accepted medical practice,” Brock added. “This is important because in general Latin America has been very behind on these issues and so it’s nice to see Argentina leading the way.”

In the United States, Oregon, Washington, and Montana are the only three states to have legalized physician-assisted suicide, procon.org reported.

“I don’t have a single doubt that we’re doing the right thing here. Of course, without a doubt there are still many other things that need to be done,” said Alfredo Martinez, a senator with the opposition Radical party, which is supporting the measure.

By tipping the balance in end-of-life decisions toward patients and their families, the law should help reform a medical system that has been far too paternalistic, with doctors or judges making decisions that ignore or conflict with the patients’ wishes, said Dr. Isabel Pincemin, the medical director of the Hospice San Camilo, which has cared for hundreds of dying people in a home just blocks from the presidential residence.

“This law is in a way an invitation to all the doctors to take into account the patient’s wishes, but what has to happen now is a cultural change,” she said. “Death is the thing most denied in our society: We have lost the understanding that death is natural, and so we too often try to maintain life even in impossible situations.”

What Argentina needs next is a palliative care law requiring health care providers to support hospices for the terminally ill, she said. There are only a half-dozen hospices in the country of 40 million, and too few people know that dying people are supposed to get pain medicine for free, she said.

“Far too many people are dying horribly bad deaths, alone and abandoned,” she said.

Robles says he’s grateful his doctor pointed him to the hospice, where he now gets close 24 attention for free.

“Hopefully no one will have to suffer,” Robles said, thinking about the law. “Nobody wants to see a person suffer.”