This report demonstrates that the elites, who influence the behavior of those involved in end-of-life care, have decided that there must be a radical change in the principles and practices of those who give that care. Pragmatic considerations must now be the dominant concern.
The Belmont Principles of patient autonomy, beneficence and justice, have provided care givers only with insoluble dilemmas. Should the patient's preferences trump the public good in regard to the use of scare resources? Does the law, as currently written, allow a proposed course of treatment? If the care givers' basic moral principles had been based on natural law and the Catholic Church's teaching, those dilemmas would not have occurred. However, the false anthropology and materialistic nature of their principles does not indicate what is good or what is just. Secular materialists have therefore, resorted to the use of a pragmatic method of achieving a consensus of stakeholders in the process of arriving at a decision about medical treatment.
Gone is the previous emphasis on patient autonomy, advanced directives, and aggressive care. The patient and/or surrogate for health care and the family are no longer to be offered choices in regard to decision-making. The process now becomes one of resolution of conflict between the patient or his or hersurrogate on the one hand, and the care-givers on the other. Conflict is to be avoided at all costs. It delays decision-making and therefore greatly increases the cost of patient care, and may also lead to litigation that is costly, time consuming.
Consensus is to be achieved by a process that involves the cooperation, if necessary, of patient and/or surrogate, the family, the physician, nurses, social workers, and a bioethicist. This is a process, termed 'reasoned discourse', that puts great pressure on the patient or surrogate, who usually know little about medicine or the law and tend to give in to that pressure.
The modern ethic of care giving recognizes only the validity of legal rights and 'ethical scholarship'. The latter, simply put, recognizes only one moral absolute, that a decision based on consensus is morally acceptable. This is a self-serving postulate, but it is vigorously promulgated none the less.
In a group discussion about a decision regarding treatment, great emphasis is put on the cost of end-of-life care and on the 'social justice problem' caused by the allocation of natural resources. Concerns about costs escalated rapidly due to the fact that contraception and abortion and the success of medical care have resulted in a greatly increased number of the elderly in relation to the number of young people who have to pay for the care of the elderly. Families of those with disability and those who emphasize the sacredness of human life for religious reasons are regarded as a problem. They tend to treat rather than forego treatment. These people, we are told, must be made "part of the conversation." The main concern is not what the patient prefers but to analyze what is in the 'best interest' of the patient. This is to be decided by a skilled 'facilitator'. If the patient is presumed to be dying, 'comfort care', rather than life sustaining treatment, is provided. This can lead to two serious moral problems. First, a patient is assumed to by dying if the physician decides that he or she will be dead within two weeks. This is at best, a rather wild guess. Secondly, comfort care involves withdrawal of hydration and nutrition. It must be remembered that this will probably hasten the patient's death by dehydration.
The Physicians' Orders For Life Sustaining Treatment (POLST) suggest that consensus about treatment, arrived at by the conversation between care-givers and the patient or surrogate should become 'orders', including 'Do not resuscitate' and 'Comfort measures only' orders. Some suggest that such a consensus be anchored in constitutional law. Others suggest social arrangements such as State End-of-Life Coalitions to develop plans to formalize methods of decision making in regard to patient care. These plans, it is suggested, should work throughout the whole health care system, including emergency rooms, long term care units, and hospices. Those involved in making the formalized plans would include physicians, nurses, and hospital lawyers. The care provided by these systematized plans would not necessarily be based on an individual patient's needs, but would "meet the need of most patients most of the time." Is this 'one-size-fits-all' imperative in any way related to a desire to cut costs?
The Hastings Report makes a point of disapproving of euthanasia, the deliberate shortening or ending of a person's life in order to relieve his or her suffering. Many palliative care physicians maintain that withdrawal of nutrition and hydration does not shorten a patient's life. This claim is seriously debated however, and indeed could not be made with certainty in any particular case. For this reason, the currently wide spread use of the withdrawal of nutrition and hydration under the rubric of comfort care, palliative care, and terminal sedation is not morally acceptable.
The Hastings Report recommends that we base the methods of palliative care on the pragmatic utilitarian principle of a consensus of stakeholders. This is to be achieved by the art of rhetoric or persuasion. The report follows in the footsteps of Richard Rorty. He was a nihilist and an atheist who did not believe in objective moral truth. He nevertheless held that one is able, by the use of the art of rhetoric, turn one's desires into the 'truth'. It is clear that pragmatic considerations of utility, and the minimization of cost, may well take precedence over the good of the individual patient. If palliative care with withdrawal of nutrition and hydration is used to prevent suffering in patients at the end of life and also in those with chronic disease, then palliative care will have become widespread euthanasia.
Incidentally, Dr. Kathleen M. Foley's article, "The Past and the Future of Palliative Care" summarizes the history of palliative care in the U.S. It does not refer to the moral principles being used by the many palliative care givers or to the teachings of the Catholic Church regarding the moral principles that should guide those care-givers.