The State Triumphs, and a Patient Dies

Once again, life imitates art. The result is not pretty.

Doc Daneeka, a fictional character in Joseph Heller’s modern classic, explains its eponymous Catch-22. A flyer can escape combat duty if he is insane. But he must request the exemption. If he does, he proves thereby that he is not insane, and therefore his application is denied.

The UK medical system succeeded in recent days of assuring the death of a 19-year-old patient with a rare disease. She wished to press on her fight to live, and enroll in a clinical trial program in another country. The British powers that be, however, claimed that asking to live meant that she was not mentally competent. If she were, she would accept the verdict of all her medical team, who were convinced that there was no hope for her. Because she wanted to live, she was not capable of making a decision – and therefore was assigned to palliative care that would hasten her death. Not exactly Catch-22, but the paradox of this decision makes it eerily similar.

Heller’s novel depicted the inconsistencies and failures of war-time military bureaucracy. There was plenty of that going on in the UK, which does not seem at the moment to be at war. A court order forbade the patient’s family from disclosing her identity, which would have helped them raise public awareness and with their legal costs. This order was lifted only after the young woman died, as demanded of her. Another order barred them from divulging the names of the hospital where she was treated, and the identities of the clinicians involved in her care. That order has still not been lifted.

This strikes me as a further devolution of the morality of the British medical and court systems. Previous high-profile cases involved children who could not signify their wishes. In those cases, the authorities refused to allow those patients to leave the country for destinations willing to try different methods to keep them alive. The government asserted that its “we know best” position trumped parental choice. (The arguments were equally tragicomic. In the case of a frum child whose parents wanted to continue treatment, the government argued that she could not be transported to Israel, because the threat of rocket attacks made the move unsafe.) In this most recent case, however, the system went up against the clearly expressed wishes of the patient herself. The court insisted that the right to life itself was subject to its approval.

This is statism at its worst. And there is no reason to believe that it won’t jump the Atlantic – or even the Mediterranean, where an eager High Court has long asserted that it knows best what is good for people, even against their expressed wishes.

Decent people ought to be screaming about this – at least till their voices are also silenced.

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12 Responses

  1. Bob Miller says:

    Does King Charles have anything to say?

  2. DK says:

    “And there is no reason to believe that it won’t jump the Atlantic – or even the Mediterranean, where an eager High Court has long asserted that it knows best what is good for people, even against their expressed wishes.”

    Scary thoughts indeed. Hashem Yishmor Aleinu!

  3. חנה סיגל says:

    “The dead man in Yossarian’s tent was not easy to live with.”

  4. william l gewirtz says:

    Sadly, I think the jump across the Atlantic has begun. When politics can affect and even silence medical or scientific views as is occurring, it is not hard to imagine governments dictating end-of-life decisions. Undoubtedly, funding decisions can be a critical first step followed by arguments about the misuse of critical resources.

    • A comment worthy of Cass Sunstein

    • mycroft says:

      Who should determine ed of life decisions? Patient-does that mean we should assist suicide of any patient that wishes to end their life? Family?-then can be prejudiced to hasten the end of life because they’ll inherit more.
      Hospitals-medical establishment-certainly, young residents and fellows often see elderly as having had their time on this earth. Many ways to unofficially hasten end under pretense of making patient more comfortable-morphine drip?
      Funding decisions impact all parties-government, families, medical establishment. No obvious good answer.

      • william l gewirtz says:

        The fact that there is as you write: “No obvious good answer” does not mean there are no bad ones. Advance directives specifying the will of the patient, their desire to follow their beliefs / religious practices as decided by a clergyman, surrogates appointed by the patient, specifications of how to behave under various circumstances, etc. alone or in combination all seem infinitely better than what occurred in the case cited in the UK.

        Hastening death by a morphine drip is halakhically mandated/permitted under specific circumstances. We may never be able to achieve perfection; even competent poskim will disagree. However, as my neurosurgeon told my cousin – never let the good be the enemy of the perfect.

  5. mycroft says:

    Advance directives specifying the will of the patient, their desire to follow their beliefs

    Advanced directives very often do not reflect people’s choices at the end. Anyway, advance directives are not the obvious correct way-ask a 20-year-old what conditions they’d want to live and will get a different answer than a 80 year old.
    Any system has cases that appear unjust ex post-problem is designing a system ex ante that is better ex poste. Halacha is a great system but its formalistic approach can yield unjust results and Gemarrah recognizes it-see e.g. case of Shimon ben Shetach’s son executed despite known false testimony-kevin shehegid shuv eno chozer .
    Re permissibility of hastening death-much more realistic problem is that society is not interested in old people without economic benefit. One can figure exactly when, but I remember being menachem avel to Mr. Abrams and Rav Moshe Tendler was there and this is probably about 55 years ago, can’t be more recent because IIRC Mr. Abrams passed away not too long after his wife passed away. I remember Rabbi Tendler mentioning that counter to press reports big issue is not people being kept alive against their will but people not being kept alive. Certainly, in practice minute by minute decisions in hospitals being done by people in late 20s not those of elder age..

    • Steven Brizel says:

      Patients relatives , and not the hospitals and the medical profession should be trusted on end of life issues , especially when there are Halachic or other religious issues that are in conflict with the desire of hospitals and physicians to provide pallliative care for a terminal patient. There are issues such as the nature and progression of any disease in such patients that much be discussed and a conclusion reached that satisfies the patient, Big Medicine and Halacha as opposed to the desire of a hospital to view a bed occupied by a patient as being underutilized and the rampany ageism against the elderly and their use to society in a non economic manner. IMO there needs to be a communal study of those who have endured these issues with parents and close relatives who are in the Olam HaEmes because they saw the facts on the ground and dealt with them in the manner that they understood was compatible withHalacha whch provides approaches, as opposed to answers, ranging from treating even Chayeei Shaah to hospice to not seeking aggresssive treatment which would cause more sufferiing as opposed to the possibility of a cure.

  6. Steven Brizel says:

    There was an article printed in Tradition for which I cannot find a link as to end of issues by a physiciian whose views were found within Halachic boundaries by both RHS and RM Willig. If someone can find that link and post the same, it would greatly enhance this conversation.

  7. Steven Brizel says:

    For those interested see this linked article

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