Then and Now: The Descent of Ethics

Nancy Valko
Voices Online Edition
Vol. XXVII, No. 2
Pentecost 2012
Reproduced with Permission
Voices Online

I feel blessed to have grown up and become a nurse in the era of TV programs like Marcus Welby, MD, Ben Casey, and Medical Center. I couldn't wait to be part of such a noble profession and I proudly recited the "Florence Nightingale Pledge," the nursing equivalent of the Hippocratic Oath, at my graduation from a Catholic nursing school in 1969.

Written in 1893 and named in honor of nurse/hero Florence Nightingale, the pledge reads:

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.1

Forty-three years later, I still subscribe to those simple but powerful principles but the healthcare world around me has changed dramatically. On the plus side, I have witnessed the great advances in treating illnesses, pain, etc. However, on the minus side, I have witnessed an increasing rejection of traditional ethics that has turned the world I knew upside-down in so many ways. In 1969, I could never have imagined that the crime of abortion would be declared a constitutional right or that euthanasia in the guise of "physician assisted suicide" would become legal in any state. And could any of us ever have imagined a time when a US president would try to force even Catholic healthcare institutions into violating their conscience rights?

These changes did not happen overnight and neither were they the result of new scientific discoveries. The tragedy is that this all began with small, deliberate steps.

Contraception and Abortion

In 1965, the American College of Obstetricians and Gynecologists (ACOG) redefined conception from the union of sperm and egg to "the implantation of a fertilized ovum,"2 allowing hormones - like those in the Pill - that can interfere with implantation to be classified as contraceptive rather than potentially abortifacient. Eventually, this opened the door not only to widespread acceptance of artificial contraception but also later developments such as abortifacient "morning after" pills, embryonic stem cell research, and in vitro fertilization (IVF).

Unsurprisingly, abortion itself was legalized a mere eight years after the ACOG redefinition of conception when the stage was already set for a pervasive contraceptive mentality making childbearing merely a "choice." Now, we not only have abortion celebrated as a right but also infertile couples who want to adopt having to compete with same-sex couples for a smaller and smaller pool of available children to love and raise. Some desperate infertile couples resort to IVF, artificial insemination, or surrogate motherhood. Today, unborn babies themselves routinely have to pass "quality control" prenatal tests to escape abortion. And just recently, two parents won almost $3 million in a "wrongful birth" lawsuit because they claimed that they would have aborted their daughter with Down Syndrome if the prenatal tests had been accurate.3

Moreover, according to two ethicists writing in a recent article in the Journal of Medical Ethics, even a newborn without disabilities does not necessarily have any right to live. Ethicists Alberto Giubilini and Francesca Minerva baldly state that "what we call 'after-birth abortion' (killing a newborn) should be permissible in all the cases where abortion is, including cases where the newborn is not disabled." This, they argue, should be permissible because, like a fetus, the newborn is only a "potential person."4

Organ Donation

In 1968, an ad hoc committee at Harvard Medical School issued a report defining a type of irreversible coma as a new criterion for death, stating that "[t]he burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and on those in need of hospital beds already occupied by these comatose patients" and the "[o]bsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation."5

Since then, all 50 states have adopted laws adding brain death to the definition of death but each hospital can determine its own, often widely varying, criteria for what counts as brain death.

When brain death did not provide enough organ donations to transplant, some ethicists and doctors devised a new way of obtaining organs. Now, we have non-heart-beating organ donation (aka donation after cardiac death) for people who do not meet the brain death definition6 and doctors like Robert Truog, who argues that the traditional "dead donor rule" before organ transplantation should be eliminated in favor of taking organs from living patients on life support with "valid consent for both withdrawing treatment and organ donation."7

In a final step, doctors in Belgium have already combined euthanasia with organ donation.8 Could this happen here? Just last year, the New York Times published an article from a death row inmate in Oregon arguing for the right to donate his organs after his own capital punishment by lethal injection, and started an organization promoting this for other prisoners.9

The "Right To Die" and Euthanasia

The 1970s brought the invention of "living wills" and the Euthanasia Society of America changed its name to the Society for the Right to Die. The so-called "right to die" movement received a real boost when the parents of Karen Quinlan, a 21-year-old woman considered "vegetative" after a probable drug overdose, "won" the right to remove her ventilator with the support of many prominent Catholic theologians. Karen continued to live 10 more years with a feeding tube, much to the surprise and dismay of some ethicists. Shortly after the Quinlan case, California passed the first "living will" law.

Originally, "living wills" only covered refusal of life-sustaining treatment for imminently dying people. There was some suspicion about this allegedly innocuous document and, here in Missouri, "living will" legislation only passed when "right to die" advocates agreed to a provision exempting food and water from the kinds of treatment to be refused.

But, it wasn't long before the parents of Missouri's Nancy Cruzan, who was also said to be in a "vegetative" state, "won" the right to withdraw her feeding tube despite her not being terminally ill or even having a "living will." The case was appealed to the US Supreme Court, which upheld Missouri law requiring "clear and convincing evidence" that Nancy Cruzan would want her feeding tube removed, but, in the end, a local judge allowed the feeding tube to be removed. Shortly after Nancy's slow death from dehydration, Senators John Danforth and Patrick Moynihan proposed the Patient Self-Determination Act (never voted upon but became law under budget reconciliation), which required all institutions to offer all patients information on "living wills" and other advance directives. Since then, such directives evolved to include not only the so-called "vegetative" state and feeding tubes but virtually any other condition a person specifies as worse than death and any medical care considered life-sustaining when that person is deemed unable to communicate.

But has this choice become an illusion? The last several years have also seen the rise of so-called futility policies and even futility laws in Texas that can override patient or family decisions to continue treatment on the basis that doctors and/or ethicists know best.

In the early 1990s, Jack Kevorkian went public with his first assisted suicide and the "right to die" debate took yet another direction. By the end of the decade, Oregon became the first state to allow physician-assisted suicide. At first, the law was portrayed as necessary for terminally ill people with allegedly unrelievable pain. Within a short time, though, it was reported that "according to their physicians, the patients requested assistance with suicide because of concern about loss of autonomy and control of bodily functions, not because of concern about inadequate control of pain or financial loss."10

In 2008, Washington became the next state to legalize assisted suicide and in 2009, Montana's state Supreme Court declared that it was not against public policy for a doctor to assist the suicide of a competent terminally ill person. Relentless efforts to legalize assisted suicide in other states have failed so far, but many euthanasia proponents support terminal sedation as a stopgap alternative to assisted suicide for the present.11 Ominously, just last year assisted suicide activist and terminal sedation advocate Dr. Timothy Quill was named president-elect of the American Academy of Hospice and Palliative Medicine (AAHPM).

In just the last few months, popular health expert Dr. Mehmet Oz voiced his support for physician-assisted suicide on his TV show and Dr. Phil McGraw hosted a segment on his widely seen TV show featuring a Canadian woman who wanted her adult disabled children to die by lethal injection. Ironically, the mother, along with former Kevorkian lawyer Geoffrey Feiger, argued that removing their feeding tubes was an "inhumane" way to end the lives of the adult children. Tragically, when the studio audience was polled, 90% were in favor of lethal injections for the disabled adults.

The Challenge Ahead

After 43 years, I don't miss the starched nursing uniforms and glass IV bottles of my youth but I certainly do miss the idealism and ethical unity that I shared with my colleagues during that time.

Back then, Catholic nursing education like mine added a level of ministry to our efforts but, Catholic or not, we all shared the common goal of providing the very best health care for every patient regardless of age, socioeconomic status, or condition. But now, in capitulation to the new ideal of "choice," we doctors and nurses find ourselves ostracized from our professional organizations for being "politically incorrect" when we oppose abortion and stand up for discrimination-free medical care for the disabled. We are warned not be "judgmental" when a terminally ill person asks to die. At the same time, we see our conscience rights being legally dismantled with excuses such as "Doctors, nurses and pharmacists choose professions that put patients' rights first. If they foresee that priority becoming problematic for them, they should choose another profession."12

This did not happen overnight but rather by small and ever deepening steps. The result has not been a more compassionate and just society but rather a culture with a false sense of power and entitlement. We have been seduced into believing not only that we deserve control over having or not having children but also the degree of perfection of those chosen children. We think we deserve a life in which the seriously ill or disabled don't financially or emotionally burden us. We think we deserve to decide when our own lives are not worth living, and have a right to be painlessly dispatched by a medical person. And we desperately but ultimately futilely want to believe that our actions and attitudes will not have terrible consequences.

It will take all of us openly and constantly challenging this culture of death to restore the traditional respect for life that protects all our lives.


1 American Nurses Association. Online at: [Back]

2 American College of Obstetricians and Gynecologists Terminology Bulletin. Terms Used in Reference to the Fetus. No. 1. Philadelphia: Davis, September, 1965. [Back]

3 "Jury awards nearly $3 million to Portland-area couple in 'wrongful birth' lawsuit against Legacy Health" by Aimee Green. The Oregonian. [Back]

4 "Killing babies no different from abortion, experts say" by Stephen Adams. The Telegraph. February 29, 2012. healthnews/9113394/Killing-babies-no-different-from-abortion-experts-say.html. [Back]

5 "A Definition of Irreversible Coma - Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, The Journal of The American Medical Association. August 1968. Excerpt [Back]

6 "Death and the Organ Donor" by Nancy Valko, RN. Voices, Eastertide 2009. [Back]

7 "The dead donor rule: can it withstand critical scrutiny? By Miller FG, Truog RD, Brock DW. Journal of Medicine and Philosophy, 2010 Jun; 35(3):299-312. Epub 2010 May 3. Abstract: [Back]

8 "Initial Experience with Transplantation of Lungs Recovered from Donors after Euthanasia". Applied Cardiopulmonary Pathophysiology 15: 38-48, 2011. [Back]

9 "Giving Life after Death Row" by Christian Longo. March 5, 2011. New York Times: [Back]

10 "Legalized Physician-Assisted Suicide in Oregon - The Second Year" by Amy D. Sullivan, PhD, MPH, Katrina Hedberg, MD, MPH, and David W. Fleming, MD. The New England Journal of Medicine, 2000; 342:598-604 February 24, 2000. [Back]

11 Timothy E. Quill, MD and Ira R. Byock, MD for the ACP-ASIM End-of-Life Care Consensus Panel, "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids", Annals of Internal Medicine. 2000; 132:408-414. Abstract: [Back]

12 "An Unconscionable Conscience Rule", St. Louis Post-Dispatch editorial, December 24, 2008: [Back]