[Marxism] On Schiavo

Andy esquincle at capital.net
Thu Apr 7 19:16:10 MDT 2005


Sorry to flog the dead subject and apologies for the length.

The New England Journal of Medicine will shortly publish two pieces on 
the Schiavo case.  They are available (no need for password) in pdf 
format at
http://content.nejm.org/early_release/index.shtml#3-22-05
I won't discuss these here, but mention them for interest in light of 
the recent enlightening discussion.  Also these articles seem to be an 
indication of how commonplace difficult end-of-life decisions have 
become in modern medical practice --  and how state intervention in 
these decisions remains utterly unwanted.

=====

A few years ago I was in training and on duty overnight.  I took a call 
from a doctor at a small rural hospital who had a patient that he 
believed had suffered an intra-abdominal catastrophe.  She had 
hypotensive shock.  Would I please accept the patient in transfer, 
since our hospital had surgeons and an ICU available (and his hospital 
had neither)?

I accepted the patient and arranged for an urgent surgical evaluation 
-- the surgical resident and I literally met the ambulance crew and saw 
the patient on their stretcher in the intensive care unit.  The patient 
clearly had an acute abdomen -- massively, tensely distended -- and she 
was quickly rushed off to the OR.

This young African-American woman, then in her 40s, had cerebral palsy. 
  Her developmental disability had proven too much for her family when 
she was still very young and so she became a ward of the state.  She 
was, when young, a patient at the infamous Willowbrook at the very time 
when its inmates were the subject of human experimentation -- 
specifically they were injected with hepatitis, -- vulnerable human 
beings intentionally made sick by American doctors as a method of 
study.

(Horrors of Willowbrook (there were other horrors too) would lead to a 
large discussion about human experimentation in American medicine, 
reforms in the care of the mentally ill and developmentally disabled 
and the creation of Institutional Review Boards to govern human 
research.  They also helped make careers for Geraldo Rivera and 
others.)

More recently, my patient had become a resident at a community-based 
home, part of the "association for retarded children" network, where 
she seemed to have a rather happy existence, requiring lots of care but 
communicating in a rudimentary way with her devoted caregivers.  Her 
biological family had also followed her through the years, and 
continued to involve themselves in her life, increasingly so as she 
aged.  Technically she remained a ward of the state.  This fact soon 
grew hugely important.

In the operating room the patient was prepped and sedated.  A midline 
incision was started.  Her peritoneal juices, under tremendous 
pressure, hit the ceiling.  The surgeons quickly determined that she 
had suffered an utter catastrophe:  her intestines, as a mass, were 
black and dead -- from the ligament of Treitz to the splenic flexure.  
The surgery lasted only minutes -- they closed their incision, as there 
was nothing they could do.

In retrospect the patient likely developed peritonitis -- perhaps 
related to her percutaneous feeding tube -- that had exploded, so 
fulminant, so severe as to cause "peritoneal tamponade" -- pressure 
inside the abdominal cavity much greater than arterial pressures to the 
intestines, enought to choke off blood supply to nearly the entire 
bowel.  The patient's condition was beyond critical.  She was terminal 
-- no hope of recovery, no matter what.  Any further care would be best 
deemed futile.

At this point the patient had become the surgeon's responsibility.  I 
was no longer directly involved in her care (also I was a medicine 
resident).  Yet I continued coming in each night, checking on her in 
the intensive care unit.

The state had no provision for withdrawal of life support from its 
wards -- all efforts, said the law, no matter what.  This "culture of 
life" had come about ironically in part as a result of the Willowbrook 
scandal.  The patient lingered on the ventilator.  The state's 
appointed decision-maker for her demanded that the hospital "do 
everything" to keep the patient alive -- knowingly against the 
unanimous wishes of her family.

Nearly all hospitals have an ethics committee (also in part because of 
the Willowbrook scandal) -- with a ground rule that anyone in the 
institution may consult that committee.  I consulted it.

Naturally I asked if the ongoing intensive care treatment of this 
patient was ethical (the committee said it wasn't) but I also asked 
something like this -- what was the ethical and moral obligation of the 
hospital to other patients under this state in light of this 
circumstance?  The ethics committee said the law was wrong and should 
be fought.  The hospital called its attorney and prepared to contest 
the law.

The patient lingered for days.  Her massive organ necrosis drew flies.  
She appeared utterly comatose and insensate, a small consolation.  Yet 
her family gathered -- and suffered !!! -- oh their anguish!  -- layers 
and layers and layers of cruel American indignities.  The judges 
dragged their feet.  The patient died.

So much for individual efforts to reform the system.

=====

In recent days at work I have struggled at the bedside of a patient 
with a particularly vicious ailment -- end-stage emphysema.  Like many 
respiratory ailments, chronic obstructive pulmonary disease can so 
cripple a body, yet the mind remains crisp.  Without mechanical 
ventilation my patient will die.  She does not want life support.   
Simple?  Not so, since, naturally, she does not want to die either.

Layer over this the (usual) profound abhorrence of nursing homes.  In 
particular (if you've ever had the chance to visit one you can picture 
it), this patient seems appalled at idea of the "chronic vent 
facility."  She thinks she would rather die than live a day in such a 
place.

She's thinking about all of this tonight.  So are her children.  
Fortunately, if only this once, we have the luxury of a few more hours 
for discussion.

But we don't have enough time, for this one woman, to build a new 
system.

=====

The TV has blared 24/7, covering, plastering, the invasive treatments 
and dying process and the fresh cadavers of Theresa Schiavo and now the 
Pope.  The "great" thinkers, politicians and TV news producers love to 
turn these into "wedge issues;"  as they run with the story they smell 
the blood in the water -- our blood -- "on a roll."  Like the 
sorcerer's apprentice they seize upon the chance to divide us against 
ourselves, clobbering us with our own fears, and relishing the chance, 
and feeling their own might.  (Their shrill pitch and clumsy hubris 
betrays an especially imperial self-image.)  While the leaders of 
American society fall all over themselves to hypocritically invoke the 
"culture of life," and cone down upon a tragic solitary woman, to probe 
and stir the murky depths of our fears, they must also do so blindly 
and with a very long stick.

Of death and dying in America, there is much to fear.  Consider that 
statistic that says that nearly 200,000 people die annually of medical 
errors.  Consider the meltdown in healthcare -- and the righteous 
mistrust of a medicsystem devoted to the profit motive.  Consider the 
ICU deaths, intensive care stays longer than 10 days for a third or 
more of those dying in hospital, with terrifying data to say that over 
half of dying patients had moderate to severe pain at some point during 
their last 3 days of life.  Consider that people would rather die than 
experience for one day long term care (a nursing home) under 
contemporary capitalism!  The objective and subjective data run deep 
here and everybody knows it.  (Heretofore in human history such 
"choices" did not exist -- kith and kin would shoulder the burden to 
their maximum ability.)

Poke that with a stick, as the American leaders have just done, and 
they might just invoke greater, not less, love and kindness.  Which is 
the opposite of what they meant to do by invoking the "culture of 
life."  No one looks to the present government as the solution anyway 
-- why not undermined its stature even more?  As Americans rush this 
week to fill out health care proxies and living wills -- an individual 
means of protecting themselves against the state -- the idea dawns -- 
might they have conjured more human solidarity instead of more fear?

The contemporary death scene often arrives as yet another mean ambush, 
an awkward and even absurd final coda to a long succession of days 
richly and systematically shortchanged of human dignity.   Naturally 
enough, human beings rise above it, finding each other despite their 
bewildered grief.  That rising requires personal struggle, for this 
cruel society begets cruel deaths that amount to another swindle, 
momentarily redeemed by individual acts (ultimately beautiful 
subversive acts) of human solidarity and love.  Yet the brutal system 
rolls on.

I write as someone who has had the unusual privilege to have attended 
many deaths (thanks to hospitals being the place where a third to half 
(or more) of American deaths occur -- and with the hospice movement 
still growing).  I have been humbled again and again by families and 
individuals rising to the occasion, pulling together, finding their 
humanity.  I have been appalled a few times at finding families sunk by 
the occasion, devolving, fist-fighting, fractured apart.

On a good day America officially musters a mean-spirited, cowardly and 
increasingly frail culture which quite lacks the capacity to catch 
death's eye even for a moment.  You could call it the American "culture 
of life."  It is a swift current to swim against, intellectually, this 
culture of denial and viciousness and preventable suffering.  Yet we 
all must take our turns as our parents, lovers, children, friends, 
neighbors, coworkers, acquaintances, etc., meet their end -- we must 
pass through the portals of the culture in which we live.  We know that 
extraordinary personal efforts emerge in the face these hideous social 
circumstances, yet officially speaking these profound personal acts 
"wouldn't interest anybody, outside of a small circle of friends."

I overheard my three year-old talking with my five year old the other 
day.  At one point in their conversation the younger one exclaimed "No! 
  I am *not* going to die."  The older one responded with characteristic 
emphasis:  "Yes you are.  We all die.  Because dying is part of life."  
Out of the mouths of babes.

For those of us who have had a chance in life -- we will not forget 
that great proportion of humanity's infants and children who suffer and 
die daily of preventable causes under the keen eye of the "culture of 
life" -- how we die depends greatly, if not entirely, upon how we have 
lived.  Our individual lives grow despite being so distorted -- so 
extirpated -- by the cruel minutiae of our social moment, our history 
and our present.  So too our deaths.  Any serious consideration of 
changing the reality of our present culture surrounding the end of life 
conjures up the crying need for social change of revolutionary 
proportions.  This society is failing us, cradle to grave.

Andy Coates

====

PS

"Then I realized a fundamental thing: For one to be a revolutionary 
doctor or to be a revolutionary at all, there must first be a 
revolution.  Isolated individual endeavor, for all its purity of 
ideals, is of no use, and the desire to sacrifice an entire lifetime to 
the noblest of ideals serves no purpose if one works alone, solitarily, 
in some corner of America, fighting against adverse governments and 
social conditions which prevent progress."  -- Che Guevara

http://www.monthlyreview.org/0105guevara.htm





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