I got life

8 01 2015

Stipulated: Adults get to make whatever boneheaded medical decisions about themselves that they want.

Stipulated: Adults do not get to make whatever boneheaded medical decisions about their children that they want.

Question: Ought a 17-year-old be able to make a boneheaded medical decision about herself?

Cassandra C. is a 17-year-old with Hodgkin lymphoma, a disease which, when treated with chemotherapy, has a high (80-85%) survival rate. Cassandra initially underwent surgery, then two rounds of chemo, before deciding that while she wants to live, she wants to do so without, in the words of her mother, Jackie Fortin, putting “poison” in her body.

It’s not a stretch for a layperson to consider chemo a poison: the patient ingests the drugs with the idea that they will kill the cancer without killing her, and it is the lucky, lucky cancer patient who isn’t sickened by this treatment.

But it is a stretch to think that there exists some other, effective, non-poisonous treatment for Hodgkin’s, not least because there is no good evidence of its existence. Some (#notall. . .) alt-med folks may think oncologists are in league with pharma companies to hide cheap and easy cures to nasty diseases, but I highly doubt there is a conspiracy of cancer docs to keep effective treatments away from their patients just so they can profit from their suffering.

In any case, if Cassandra were 18, she could cease the chemo in search of those non-poisonous treatments, but at not-quite-17-and-a-half, she’s been confined to medical ward by Connecticut state officials and forced to undergo treatment; the Connecticut Supreme Court just reaffirmed that decision by those officials.

Art Caplan (from whom I took a class when he was at Minnesota) wrote a brief editorial that 17 is 17—that is, not 18, and therefore unable to medical decisions on her own behalf. I get the technical point (1718), but I’m not so sure that the consequentialist argument Caplan goes on to make—Hodgkin lymphoma is treatable—ought to carry the day.

After all, if she turned 18 tomorrow, the lymphoma would remain just as treatable, and the absence of that treatment would leave her just as dead.

Cassandra told the AP that

it disgusts her to have “such toxic harmful drugs” in her body and she’d like to explore alternative treatments. She said by text she understands “death is the outcome of refusing chemo” but believes in “the quality of my life, not the quantity.”

“Being forced into the surgery and chemo has traumatized me,” Cassandra wrote in her text. “I do believe I am mature enough to make the decision to refuse the chemo, but it shouldn’t be about maturity, it should be a given human right to decide what you want and don’t want for your own body.”

It is about maturity, actually; the difficulty is determining what counts as maturity?

Is it just about age? Reach 18 years and you’re mature; prior to that, not.

That has both the benefit and drawback of simplicity. It’s a straightforward standard, but one which, strictly applied, seems nonsensical, ascribing a substantive ethical property to passage of time : “January 1 you’re immature, but October 1 you’re mature.”

Age matters—if Cassandra were 10, I’d think there was no ethical problem—but largely as a stand-in for other properties, including the ability to make decisions.

So is maturity about decision-making ability? Well, okay, but what does this mean? Is this about making good (by whatever metric) decisions? And what if someone repeatedly makes bad (b.w.m.) decisions?

If their adults, and those decisions are of a non-criminal nature, we say, Okay, but largely because most of us don’t want to live in a society where we don’t get make decisions about our own lives. We assert the procedural right to decide, regardless of the content of the decision, because we’d rather make our own decisions (good and bad) than have others make them for us.

But teenagers, man, teenagers get to make some decisions and not others, and figuring out what decisions they get to make often does come down to the content of those decisions. If the kid makes good decisions (as determined by the parents), he’s given the leeway to make even more; if not, then not.

And thus the Connecticut Supreme Court has judged the procedural ability of Cassandra to make her own medical decisions on the content of those decisions: it thinks she’s decided badly, and as a result, ought not be able to decide at all.

I get this, I do, but I am made uneasy by it.  What if she had a different disease, with a much lower (40 percent? 30?) survival rate? What if the treatment were more disabling over the long-term? Or what if she doesn’t respond to the treatment? Is there any amount of suffering from the treatment that would lead the hospital to stop?

Or will they only stop when Cassandra turns 18, and is free to decide for herself, whatever the content of that decision?

This is a tough case, and I don’t know that the Court got it wrong. I just don’t know if they got it right, either.

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We might as well try: Dum de dum dum DUM (I)

8 10 2012

Guts are stupid.

Whenever someone says go with your gut or what is your gut telling you, I roll my eyes, or go half-lidded and twist my mouth, or mutter, guts are stupid.

Of course, most of those who advise recourse to our alimentary anatomy speak figuratively, not literally. They’re not really saying Listen to your colon or Ponder your digestive system or Meditate on your viscera; that would be silly.

But it is just as silly to advise people to forgo their reasoning abilities in favor of the so-called wisdom of the body.

Our bodies are not wise.

Yes, they have needs, and we need to pay attention to those needs, but in paying attention the wisdom is located in the attentiveness itself, not the thing to which our attention is drawn. Our bodies send us signals that we may then interpret as pain or pleasure or need, but, again, any wisdom is in the interpretation, not the signal itself.

So, too, may we have physical reactions to people or situations. I’ve been around folks who’ve creeped me out and have chosen to go this way rather that just because, but is this due to my spidey sense, or, again, to attentiveness to the signals I’m getting from those folks or the environment?

I’m quite willing to allow for a role for the subconscious, that is, that there are processes not under my conscious control which detect the presence of murmurings below the surface, but the subconscious is just that, sub-conscious.

It ain’t guts.

I might be particularly biased against gut-checks because my gut is so often wrong—or should I say, when I did listen to my gut I usually made the wrong decision. I am a very reactive person, very VERY reactive, so much so that if I have a strong reaction to something or someone, I make sure NOT to respond to that reaction. No, what I need to do is wait, think, then think some more before making any decisions or judgements. If I let my gut dictate my response, I would often be yelling NO or throwing things out the window or running in the opposite direction.

Am I confusing initial reactions to gut-knowledge? Perhaps, although those who state that our guts can speak are likely confusing guts with experience or habit or the skill gained through practice: when one is used to dealing with routine situations, it is possible to be sensitized to detours from the routine.

But what about those moments of indecision, when consulting one’s entrails is recommended as a suitable method of adjudication likely to lead to reliable results? Well, you probably a) are already leaning toward one side, such that tipping over feels right (or reeling back feels wrong), or b) you honestly don’t know and are simply relieved to have chosen at all.

At which point you might as well have flipped a coin.