Brits throwing Granny Under the Tram?

A century-and-a-half ago, give or take a few years, a clinical/philosophical battle raged around the issue of surgical anesthesia. A school of thought, the "heroic" school, asserted that no morbidity or mortality was justified for the mere alleviation of pain and suffering, and they plainly rejected ether or chloroform on that grounds. Citing scripture and asserting a belief that pain was necessary for healing, they nevertheless gave way before a utilitarian understanding that the advantages of surgical anesthesia were worth some risk, and a relatively high risk it was. While anesthesia enjoys a mortality rate of probably 1:250000 now, in 1850 it was probably more like 1:300 give-or-take.Over the decades the same utilitarian calculus has been worked countless times for every therapy, from antibiotics (anaphylaxis! Stevens Johnson syndrome!) to elective cholecystectomy (bleeding! infection! Death!). A weighing of risk versus benefit.

In this case, The Liverpool Care Pathway, a protocol for providing comfort to patients who are judged by their caregivers as being close to the end-of-life, has been indicted as theoretically precipitating untimely death. The indictment is anecdotal opinion, but is reasonable in its concern; that the withholding of nutrition and hydration, and the administration of narcotics and sedation for the amelioration of pain can provoke death in a patient who in fact might not have otherwise died near term.How does this differ from the decision to extirpate an otherwise healthy 35 year old's gall bladder, based upon their colicky intolerance of mexican food, knowing that there is a distinct, if rare, incidence of death? Well, I suppose one could argue that the 35 year old is able to give informed consent, although I have yet to believe that any lay patient understands the risk of pulmonary embolus or common duct ligation. 

Could it be the relative imminence of death inherent in the decision to withdraw support? If so, then the issue is merely one of popular lack of understanding, since nothing is quite so dramatically imminent as a saddle pulmonary embolus in an otherwise healthy 35 year old.

Or are we uncomfortable because they are potentially "burying their mistakes" beyond the reach of oversight by virtue of the very nature of the intervention (or withdrawal thereof).

Or is it that there is an insidious dual-agency conflict here, with the care team acting as an economic agent of the state, callously inducing health care efficiencies by knocking off granny a couple of days, (or weeks?) early. Well, maybe. And maybe, the anecdotal warning of the experts is just that; a warning that one must be particularly careful about diagnosing futility prior to instituting self-fulfilling care plans. As they say in drowning resuscitation, the patient is not dead until they are WARM and dead, as a reminder that hypothermia can mask a survivable situation. And just maybe in turn, that warning was grasped by a controversy-hungry newsperson, preying upon the public mistrust of impersonal beaurocracy to gin up a little newsProbably it's all of the above, but the question remains, do the benefits of not forcing the dying to linger in suffering outweigh the risks of early death for the few who might have lived a little longer, or supersede the concern that compassionate facilitation becomes hard-hearted sacrifice for the "public good." 

 I'm with Ross Douthat in his recent op-ed on "slippery-slope"-ism in euthanasia. (And the Liverpool Care Plan certainly is euthanasia though late term euthanasia it may be.) On my list of likely slopes to slide down, the euthanasia-as-cost savings risk is pretty far down my worry list, Sen Grassley and citizen Palin notwithstanding.