Making Hard Decisions...

Recently I was involved in an on-line discussion about how the Canadian Medicare system may need to change. The change may mean making hard decisions about what care is "medically necessary", about prioritizing what treatment is offered to whom. The ethics of medicine get very complicated with increasing ability but limited resources. It reminded me of this column I wrote last March in response to the Terry Schiavo case...

The recent death of Terry Schiavo has me thinking about 3 simple, interrelated questions: Can I? May I? Should I?

Despite what we might think all three of these are totally different.

"Can I?" is a question of ability and/or resources. It simply is a way to determine if something is possible or a goal is attainable.

"May I?" is often confused with "Can I?" (how many of us have had occasion to correct children in our care on this one). It is a question not of ability but of permission, of who is allowed to do something.

Then we have "Should I?". This is the ethical question. It is the hardest one to answer (the other two are relatively easy after all). Much of the debate about Terry Schiavo focused on the "May I?", on whom has the authority to make decisions about her care, the ability (Can I?) to prolong life was obviously there. It sometimes seemed that the ethical ("Should I?") question was obscured by rhetoric and entrenched positions on both sides.

"Should I?" is always a hard question. And the more complex an issue the harder the question it becomes. It is my belief that in the next generation we will be faced more and more by issues around the right to die (even if some say such a right doesn't exist), the right to refuse treatment, and the question of who makes decisions for me when I am no longer competent. This is largely because the "Can I?" question is more and more often answered affirmatively. If there are no options then decisions are much clearer. And this is where the church and other faith communities HAVE to stand up and be counted. We have to encourage people to address and explore the "Should I?" questions BEFORE they are gathered around a hospital bed.

I do not pretend to have the ability to answer these questions. That would be insufferable arrogance. This is not a question about if we are playing God; it is a question of how we choose to play God. And I am not sure that we will ever find one answer that works across the board, as nice as that would be. No, our job is not the find the one definitive answer, it is to help open up the questions. And to help the people around us make it known to their loved ones what their feelings would be if they became incompetent to give consent to treatment.

"Talk to your families!" is the one piece of advice that rings in my ears whenever someone brings up a case like this. Talk about when treatment should be continued and when it may be time to say "enough". It is not enough to sign a piece of paper with your wishes. You have to let your loved ones know too. (The same thing goes for signing an organ donor card by the way) You have to let them know because they will be the ones looking at the Dr. in disbelief when (s)he says that (s)he knows better what you would have wanted.

This is our task, to bring light to bear on the hard questions. Scientists and lawyers can answer "Can I?" and "May I?" but we have to help people deal with "Should I?". We ignore that question at our own peril.