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Samuel Golubchuk euthanasia update:

Late last year, I wrote about the case of Samuel Golubchuk, an elderly Canadian man whom his doctors wish to euthanize, over the strong objections of his orthodox Jewish family. (Hastening someone's death by withdrawing life support is known as "non-aggressive euthanasia.") A recent policy statement from the College of Physicians and Surgeons of Manitoba, asserts the power and the duty of physicians to euthanize patients, notwithstanding the objections of the patient or his family. Last week, a Winnipeg trial court issued an injunction requiring continued care for Mr. Golubchuk, pending a full trial on the merits.

According to the decision, Golubchuk's relatives

have produced an affidavit of a neurologist who practises in New York and has reviewed the entire hospital record of Grace Hospital. He has noted an absence of any examination of the plaintiff by a neurologist, any brain-imaging such as with CT scan or MRI, or other measurement of brain activity. He stated that the record contains many references to the plaintiff being awake and making purposeful movements that have not been reported by or explained by the defendants' deponents. He stated that the plaintiff has not been assessed for aphasia, locked-in syndrome or other treatable neurological illnesses, which could account for his apparent lack of consciousness. He concluded on that point:
11. Furthermore, according to the documentation in the medical records, Mr. Golubchuk's condition has demonstrably improved (Exhibit "D"). There is no evidence whatsoever that he is brain dead, close to brain dead, or dying, from a neurological point of view. He has enough higher cognitive function to not only be considered awake but to make frequent, purposeful movements and engage in other purposeful activities.
The court rejected the hospital's claim that settled law allowed a physician to terminate life-sustaining treatment over the objections of a patient or family. Further, wrote the court, it was possible that Golubchuk had a right to treatment under the Canadian Charter of Rights and Freedoms, or the common law. In light of the balance of equities (that Golubchuk would suffer an irreparable injury, namely death, without an injunction), the court enjoined the hospital from euthanising Golubchuk pending trial on the merits.

I was surprised to find that the name of the hospital that wants to euthanise Golubchuk is the Salvation Army Grace General Hospital, which according to its website, is a "faith-based" facility.

33yearprof:
There's a disconnect here.

Physicians won't assist the state to humanely execute convicted murders.

Physicians want to be free to kill, through neglect, innocent old men.

Situational ethics?
2.18.2008 8:34pm
Daniel Chapman (mail):
Another reason to not like the salvation army... my favorite so far was the case where they evicted a single, working mother of two from their shelter because she got pregnant. "Your family is now too large for the apartment, and we don't have any larger ones available. Be out by the end of the month please." All while running their program with the federal SHP grant too...
2.18.2008 8:46pm
Thoughtful (mail):
Now you know who wins when you pit faith against socialized medicine. The physicians and hospitals in Canada aren't getting paid to treat chronic long-term "problems" like Mr. Golubchuk. Doctors quickly come to view themselves as responsible for assuring that the now limited number of CTs and MRs that are paid for each year go to "proper" patients, those who might be (most) helped.

No one works for free in the healing professions. I'm sure if the total amount spent on legal services were capped by the state, lawyers in Canada wouldn't want to defend Mr. Golubchuk either...
2.18.2008 8:47pm
great unknown (mail):
33yearprof:
I wonder what would happen if states paid physicians enough, and often enough, to make "execution medicine" a lucrative profession. How soon before it would become a recognized specialty?
2.18.2008 8:56pm
Visitor Again:
Another reason to not like the salvation army

The only time I was ever physically attacked as a lawyer by someone other than law enforcement:

I was representing before the Santa Monica Renters' Rights Commission a group of elderly low income people whose ouster from low-cost rent-controlled housing was sought by the new owner of the property, the Salvation Army, which wanted to build a new Salvation Army center on the site. The hearing was packed with Salvtion Army members. At a recess while standing in a crowd in the hallway enjoying a smoke, I suddenly found myself gasping for breath with a terrible pain in my ribs.

A little old lady in Salvation Army get-up had twice jabbed me very powerfully in the ribs with her elbow. I swear I heard her cackle as she walked away. No doubt she thought she'd struck a blow against the forces of Satan.

Complaining about a little old lady assaulting me was beneath me, and I took it in stride, or so I thought. I went to the men's room, relieved myself, dashed some water on my face and returned to the hearing. I thought I saw the Commission president, a middle-aged woman, give a start a few minutes later when I walked up and began my presentation. It was only after I finished that I found I'd left my fly wide open--with not a word from anyone. Not one of my best nights, although the Salvation Army eventually had to pay a fair sum in relocation costs to the tenants. But beware; the Salvation Army is militant! Hee, hee.
2.18.2008 9:17pm
CDU (mail) (www):
There's a disconnect here.

Physicians won't assist the state to humanely execute convicted murders.

Physicians want to be free to kill, through neglect, innocent old men.

Situational ethics?
Evidently the Hippocratic Oath doesn't have a, "or, through inaction, allow a human being to come to harm" clause like the First Law of Robotics does.
2.18.2008 10:05pm
DaSarge (mail):
Contrast the law here in WA. We just had a case that is close factually and pretty much square-on legally:

Even if we were to recognize that a patient may choose to refuse life-sustaining treatment as a personal medical decision, that is not to say that a physician may unilaterally impose such a value preference under the guise of an expert medical judgment. The right to refuse life-sustaining treatment belongs to the patient. Until the patient exercises that right, "physicians are under an ethical, moral and legal duty to treat the patient so as to advance his recovery and alleviate his suffering." (cite omitted)

Stewart-Graves v. Vaughn
2.18.2008 10:50pm
neurodoc:
Truly incredible things have been said by lawyers representing the doctors when families have gone to court to stop them from withholding/withdrawing from their relatives life-sustaining treatment, as they tried to do in Mr. Golubchuk's case. For example, when Zongwu Jin unexpectedly recovered consciousness following a severe head injury and showed impressive neurologic improvement, his doctors having testified the man was in a "persistent vegetative state" with no hope of recovery, the National Post reported (11/22/07):
The Calgary Health Region, which runs Foothills, felt compelled to challenge what it considered a worrisome precedent, said David Weyant, a lawyer for the organization.

"The physicians were rightly concerned because if the patient had gone into arrest, they would have been required to perform aggressive and potentially harmful CPR and other resuscitative measures or face being held in contempt of court," he said.

"The physicians need to be able to make these decisions without interference from the courts... Consider a far-fetched circumstance in which a court ordered a physician to remove the wrong limb or organ; the physician must then choose to either be in contempt of court or abandon his or her professional and ethical beliefs and obligations to comply with the court order." (emphasis added)


It seems that Canadian physicians, with the backing of their professional organizations (e.g., the Canadian Medical Association and the College of Physicians and Surgeons of Manitoba), are aghast that anyone, even a court, should question their right to have the final say on who shall live and who shall die determination.

[Note: nobody has maintained that Mr. Golubchuk is "brain dead" as that term is generally understood for medical and legal purposes. And the defense's expert, who never examined Mr. Golubchuk, conceded in effect that Mr. Golubchuk wasn't in a "persistent vegetative state (PVS)" a la Terri Schiavo either, but in his opinion was best described as "nearly vegetative" or perhaps in a "minimally conscious state." During the 4 months that Mr. Golubchuk has been hospitalized to date, he has never been evaluated by a neurologist.]
2.18.2008 11:17pm
Respondent:
"The physicians were rightly concerned because if the patient had gone into arrest, they would have been required to perform aggressive and potentially harmful CPR and other resuscitative measures or face being held in contempt of court"

Neurodoc,

Perhaps you can explain this baffling statement. In what way can CPR be potentially harmful? If it doesn't work, you're no worse off than without it. If it works, hey, you're alive. Broken ribs? My ribcage hurts me as I type this but I sure as hell wouldn't rather be dead than experience a pain in the ribs!
2.18.2008 11:34pm
jvarisco (www):
This seems less about if they have a right to kill him, but more about if they are required to keep him alive for free. The reason we have so much choice in our medical treatments here is simple: we pay for them. If his family wanted to move him to the US and put him in a private hospital, I'm sure that would be fine. Just another problem with socialized medicine.
2.18.2008 11:47pm
Randy R. (mail):
Interesting how "faith" interpretes things. You can't use artificial means to prevent life, aka, contraception. But you can and must use artificial means to prolong life, aka, keeping one on life support.
2.18.2008 11:59pm
Randy R. (mail):
I've heard that a huge chunk of our medical health care costs are expended in the last ten days of a person's life.

Perhaps if we simply didn't go through these 'heroic'' yet futile measures, we could solve our health care problems?

And before anyone starts on me because I'm coldly evaluating money vs. a life, please remember that corporations and governments do it all the time, to the approval of most libertarians and conservatives.
2.19.2008 12:02am
MDJD2B (mail):

I've heard that a huge chunk of our medical health care costs are expended in the last ten days of a person's life.

Perhaps if we simply didn't go through these 'heroic'' yet futile measures, we could solve our health care problems?

A tremendous amount of money is spent on care at the end of life. Unfortunately, doctors haven't figured out how to tell in advance that someone will die in 10, or 30, days.

There is no question that the medical profession can do more than society cn offord. The question is how this should be rationed. That is a decision that society should make.


"The physicians need to be able to make these decisions without interference from the courts... Consider a far-fetched circumstance in which a court ordered a physician to remove the wrong limb or organ; the physician must then choose to either be in contempt of court or abandon his or her professional and ethical beliefs and obligations to comply with the court order."

A court order to remove the wrong organ is a red herring in the US or Canada. Nor do courts ouder us docs to hospitalize psople for believing in capitalism. When the docors' wishes oppose a patient's or a family's, then someone must arbitrate. and this leads back to the question of who rations, and how. Default is that you get what you can afford, period. this is incompatible with the way most Americans (and people from other places) want to run their societies. But it is not obvious how care should be allocated when the government, or insurance, is paying the freight.
2.19.2008 12:20am
neurodoc:
Respondent, I can't explain the notion of doing "harm" to the patient by attempting to resuscitate him/her, since I don't understand it myself. I suppose the argument is that they might manage to get the heart beating again, but not leave the person in a state they would want to be in if they could chose. That, though, doesn't answer the question of whether the final decision to attempt or not attempt resuscitation (or withdrawal of life-sustaining treatment) should be the physicians' no matter the patient's wishes or those of his/her family.

Randy R. threw in the "F" word there, that is "futile," which is a key medical issue. Will continued care be anything other than "futile" because the patient is barely alive, and less than aware of self and environment. In Mr. Golubchuk's case, the physicians attending him have not taken the necessary steps to establish his level of neurologic function, yet they are ready to declare continued care "futile" and withdraw life-sustaining treatment. (The man can breath without a ventilator for hours at a time, but he cannot keep going on his own, his oxygen levels falling eventually requiring the ventilator once more. The real unsettled question is whether he is in at least a "minimally conscious state" or not.)

The Canadian doctors are not arguing economics, though that may be an important consideration for the health care system there; they are arguing that what they would do is the ethical thing under the circumstances, and that courts should not stick their noses in and possibly stop them.

There are profound implications to these Canadian "futility" cases.
2.19.2008 12:43am
neurodoc:
Respondent, I can't explain the notion of doing "harm" to the patient by attempting to resuscitate him/her, since I don't understand it myself. I suppose the argument is that they might manage to get the heart beating again, but not leave the person in a state they would want to be in if they could chose. That, though, doesn't answer the question of whether the final decision to attempt or not attempt resuscitation (or withdrawal of life-sustaining treatment) should be the physicians' no matter the patient's wishes or those of his/her family.

Randy R. threw in the "F" word there, that is "futile," which is a key medical issue. Will continued care be anything other than "futile" because the patient is barely alive, and less than aware of self and environment. In Mr. Golubchuk's case, the physicians attending him have not taken the necessary steps to establish his level of neurologic function, yet they are ready to declare continued care "futile" and withdraw life-sustaining treatment. (The man can breath without a ventilator for hours at a time, but he cannot keep going on his own, his oxygen levels falling eventually requiring the ventilator once more. The real unsettled question is whether he is in at least a "minimally conscious state" or not.)

The Canadian doctors are not arguing economics, though that may be an important consideration for the health care system there; they are arguing that what they would do is the ethical thing under the circumstances, and that courts should not stick their noses in and possibly stop them.

There are profound implications to these Canadian "futility" cases.
2.19.2008 12:43am
Cole M. (mail):
In the end this is a question of who rightly has the power to decide when to stop trying to keep someone alive and simply make an unavoidable death as painless as possible. Given an example like this, doctors don't seems to be the best choice. Their decisions are more likely to be driven be economic considerations (how much is this costing the hospital, etc.) and perhaps a sense of superiority (I know better than the family what is good for so and so). Clearly, not all doctors will be like this, and there are many whose care and concern for their patients will match that of the patient's family. But it is much safer to err on the side of the family; they are much more likely to have the patient's interests first and foremost in their minds and hearts. Give them the final say when the patient's own wishes are unknown, secure it in law, and there will be far fewer tragic situations like this.
2.19.2008 3:06am
Cornellian (mail):
Now you know who wins when you pit faith against socialized medicine. The physicians and hospitals in Canada aren't getting paid to treat chronic long-term "problems" like Mr. Golubchuk.

What makes you think they're not getting paid?
2.19.2008 3:21am
Thoughtful (mail):
Cornellian wonders how I know Mr. Golubchuk's doctors aren't getting paid.

It is my understanding that in Canada for each type of medical procedure a physician's annual earnings are capped. As such, people who need daily and chronic care tend to overburden the system compared to people easily treated once for an acute transient problem. In my specialty, radiology, for example, one is compensated for the first, say, 5000 CTs a year. So staying open long hours to make sure patients get CTs doesn't happen. CT scanners run 9 to 5, 5 days a week, and if you have to wait many weeks for a CT, so be it. I'm told many Canadian physicians work January through September or October because by that point they've already made all they can make for the year.

Now I admit it's been several years since I looked into the matter in any detail (when a former colleague of mine joined the group from a practice in Canada). But I've not heard of any major changes in this universal coverage system.
2.19.2008 4:11am
Thoughtful (mail):
Cornellian wonders how I know Mr. Golubchuk's doctors aren't getting paid.

It is my understanding that in Canada for each type of medical procedure a physician's annual earnings are capped. As such, people who need daily and chronic care tend to overburden the system compared to people easily treated once for an acute transient problem. In my specialty, radiology, for example, one is compensated for the first, say, 5000 CTs a year. So staying open long hours to make sure patients get CTs doesn't happen. Many CT scanners run 9 to 5, 5 days a week, and if you have to wait many weeks for a CT, so be it. I'm told many Canadian physicians work January through September or October because by that point they've already made all they can make for the year.

Now I admit it's been several years since I looked into the matter in any detail (when a former colleague of mine joined the group from a practice in Canada). But I've not heard of any major changes in this universal coverage system.
2.19.2008 4:12am
dearieme:
What is the relevance of his family being "orthodox Jewish"?
2.19.2008 6:41am
Brett Bellmore:

Perhaps you can explain this baffling statement. In what way can CPR be potentially harmful?


Well, in a out of hospital context, it's been found that even properly executed CPR frequently doesn't deliver enough blood flow to the brain to prevent brain damage, so if extended CPR is required, and isn't followed up by a protocol for recovering patients properly from extended anoxia, (Which is available, but not widely implemented.) you often preserve the patient's life at the expense of considerable brain damage.

But this problem is generally NOT applicable to hospitals, where the patient can be placed on life support promptly, instead of having their chest thumped for 1/2 hour or more.
2.19.2008 7:37am
MDJD2B (mail):

What is the relevance of his family being "orthodox Jewish"?

Possibly that Orthodox Jewish practice and/or belief insists on/requires more aggressive care at the end of life than is the case with most other belief systems. On the one hand, this creates a problem of belief versus economic imperatives. On the other hand, unsympathetic people accustomed to dealing with Orthodox Jews may think they are crying "wolf" when they demand care for decrepit members of their community whou amy be approaching the end of life.
2.19.2008 9:56am
Richard Aubrey (mail):
Some years ago--detailed in "Koop", the Indiana supremes authorized the no-support option for a handicapped infant.
It appears simply that the parents didn't want him.
So the hospital ceased food and water. The poor kid died of starvation and dehydration. One hopes his handicap made it impossible to feel pain, but I gather it did not.
But for some reason, and I talked to a shit-eating pastor who got all gushy about "being with" the family through that, nobody wanted to OD the poor kid with Demerol. When I asked said shiteating pastor why not, he immediately switched from Iknoweverything to Iknownothing.
Bastard.
Anyway, the clean-hands approach is not particularly charming, is it?
2.19.2008 12:14pm
Randy R. (mail):
As an aside, my doctor and his wife (who is his office manager) told me that you would be stunned to know how many times a rabbi, minister or pastor has come to them wanting to declare a person incompetent so that they can be the power of attorney. In most cases, the person was fine, but the 'man of faith' couldn't wait to get a hold of the person's assets. She emphasized that this happens a lot more than you would think.

The doctor in each case, refuses to certify that the person is incompetent, unless he truly believes it is so, to his credit. But he catches a lot of flack from these bastards.
2.19.2008 1:12pm
Randy R. (mail):
There should be mandatory and standardized medical tests to determine whether a person is in an irreversible coma, vegetative state, or whatever, to determine whether the person will ever be able to live without life support.

I don't know -- come up with anything you like. Have an appeals process built in. Let the family's wishes be considered. If there is a living will, that should be given great weight. Whatever.
But once several doctors sign off on it saying that basically you have a dead person in all but name, then, in my opinion, that should give them the authority to pull the plug. Spare us the agony and the medical costs. Shift the funds to helping people who actually need medical care.
Yes, I've made it clear in writing and verbally to my family that no heroic efforts should be used, and if I'm done for, then let me go.
2.19.2008 1:16pm
x (mail):
Google Sun Hudson, or Spiro Nikolouzos, both subject to the Texas Futile Care Law. The Texas law (signed by GWBush) allows a medical facility to terminate life support contrary to the family/guardian wishes. Sun Hudson was the first, I think, Spiro got moved to a different facility and died there. Both patients were non-vegetative. It's about the money. The state doesn't have to keep paying if the family can't.
2.19.2008 3:49pm
Jeremy Pierce (mail) (www):
As I understand it, the connection between the Salvation Army (the church) and the Salvation Army (the charity organization and its various branches) isn't as strong as you would think when hearing that it's a faith-based organization. Perhaps in Canadian Salvation Army hospitals it's even more tenuous.
2.19.2008 5:49pm
Brian G (mail) (www):
I wish I knew why this method isn't the same one used for executions here. After it, it's humane, right?
2.19.2008 6:38pm
x (mail):
Correction, I think Spiro may have been vegetative. Sun Hudson was heavily sedated but not vegetative.
2.19.2008 7:16pm
mischief (mail):

Possibly that Orthodox Jewish practice and/or belief insists on/requires more aggressive care at the end of life than is the case with most other belief systems.


That is true from what I have read. (Indeed, much stricter than Catholic beliefs, with which I am more familiar.)

Here is an Orthodox discussion that touches on this issue: Jews must not violate the Sabbath to build the Temple. However, in order to save a human life, even for a few minutes, they must violate the Sabbath.
2.19.2008 9:57pm
Yankev (mail):

it's humane, right?
Just because something is humane when you do it to someone who is sick and elderly and has become a burden on the medical system is no reason it would be considered humane when you do it to a convicted serial murderer.

If that's your standard, we would execute people by jamming a scissors into their brain. Everyone knows that method is humane so long as the infant's head is still in utero, even if the majority of the infant's body has already been delivered.

The convicted murderer, unlike the elderly person or the infant, has done nothing that would make the ACLU consider his life to be forefeit.
2.20.2008 4:38pm
neurodoc:
Too bad this thread wandered off to "economics" rather than sticking with the issue presented to the court, that being whether physicians are entitled to the last say in these end-of-life matters. The physician defendants and their professional associations are insistent that they do and courts shouldn't intermeddle. To be sure, "economics" and the notion of "rationing" lurk in the background, but the Golubchuk case might have unfolded in exactly the same way if the family was paying every nickel of the tab themselves. And after the question of whose decision it is to make, there are other important legal and ethical questions that should be asked and answered before attention turns to "economics"/"rationing."
2.20.2008 5:20pm