By Burke J. Balch, J.D.
Director, NRLC Dep't of Medical Ethics
Much of the drive for euthanasia relies on the premise that life
is not worth living if its "quality" is low. Indeed, many ethicists
have advocated denial of lifesaving medical treatment even against the will
of patients and their families if, in the words of Chris Hackler and Dr.
Charles Hiller, they have "views about suffering and quality of life
[that] differ substantially from those of most reasonable people."
However, a recent study of hospitalized patients 80 and older strongly
undermines the assumption that the "quality of life ethic" is
shared by "most reasonable people." Published February 4, 1998,
in the Journal of the American Medical Association, it found that
when asked to choose between a shorter lifespan with a higher quality of
life or a longer lifespan with a lower quality of life, most chose the longer
lifespan.
The study authors described the results: "On average, patients indicated
a fairly strong 'will to live': 40.8% were unwilling to exchange any time
in their current state of health for a shorter time in excellent health,
and 27.8% were willing to give up at most 1 month of 12 in return for excellent
health." Thus, "more than two thirds of the patients [68.6%] were
willing to forgo at most 1 month of 12."
Surviving patients interviewed a year later were even less likely to be
willing to give up lifespan for a better quality of life: "on average,
the time patients would give up in their current state of health to be able
to be in excellent health had declined by 2 weeks."
The study also found that surrogates who were interviewed - - family members
and others who would make decisions about lifesaving treatment if patients
were no longer able to make such decisions themselves - - were significantly
more likely to think the patient would prefer a better quality of
life to extended lifespan than the patient. Indeed, over 1 in 5 surrogates
(20.3%) "underestimated the patient's time-trade-off score by 0.25
(3 months of 12) or more."
The article noted that other studies have shown that "elderly patients
receive fewer invasive procedures and less resource-intensive hospital care
than younger patients, even when differences in severity of illness and
preferences for life-extending care are taken into account."
Commenting on the study in a February 17, 1998, Washington Post
article, Dr. Christine K. Cassel, chair of the department of geriatrics
at Mount Sinai Medical Center in New York, said its findings paralleled
her experience with her own patients.
"There's no reason why someone who's living with some chronic illnesses
should feel that life is not worth living. It tells us that human beings
are adaptable and resourceful," she told the Post.
The lead author of the study, Joel Tsevat of the University of Cincinnati
Medical Center, agreed. According to the Post, "To Tsevat the results
suggest that a powerful force may underlie the reluctance to trade time
for health: adaptation. Numerous studies, he noted, have found that people
tend to adapt to illness or disability that they might have previously considered
unendurable."
NRLC Executive Director David N. O'Steen, Ph.D., said, "Far too many
people who have not yet experienced disability assume they would want to
die if they became disabled, and project this view on older people and others
with disabilities. Yet as this study demonstrates, most who actually become
disabled find life worth living."
O'Steen added, "People who are filling out advance directives should
be extremely cautious about directing the rejection of treatment they might
later decide they want, and doctors and hospitals must stop assuming that
those who are old and disabled are better off dead."