Monday, October 15, 2012

Debating Physician-Assisted Suicide in Massachusetts

It's election season. And you know what that means: lots of vague generalities that sound like they mean something, ad hominem attacks, creativity with facts and annoying ad after annoying ad. Oh, and topics that get people really worked up, causing people to heatedly argue with each other, often to the point of intense anger. Many of these really are not worth fighting about and, regardless of the outcome, have little, if any, significance. Others, however, really are important and worth resolving and involve difficult ethical issues.

In Massachusetts, one such ethical conundrum is on the ballot: physician-assisted suicide.

A proposal has been placed on the ballot to enact a law that, if passed, would allow a licensed physician to prescribe medication that would allow a terminally ill patient to end their life. There are a number of requirements, both for the patient making the request and the attending physician. For example, the patient must:
  • be an adult (i.e., 18 years of age or older);
  • be mentally capable of making an informed decision;
  • be diagnosed with a disease which, within reasonable medical judgment, is incurable, irreversible and will result in death within six months; and
  • voluntarily express their own wish to end their life.
The patient's physician needs to confirm the diagnosis and the patient's mental state, a consulting physician must do the same. Alternatives, like palliative care, hospice care, and so forth, must also be explained to the patient, and the patient needs to sign a written statement of their intentions. Finally, before the medications are prescribed, the physician must confirm, again, that the patient really wants to go through with it, giving them another opportunity to back out. Go take a look at the full text of the ballot question for the full details.

On Friday, I had the opportunity to hear two physicians debate the issue: an anesthesiologist in favor and a pulmonary and critical care specialist against.

The pro argument was brief and to the point. He started by stating that the matter, which seems quite complex at first, becomes quite simple when you remove faith-based arguments. We allow people to live however they choose to live, as long as they do not harm others, but when it comes to death, we don't let people choose when and how they die. This question, he said, is about patient choice, stressing that it is the patient who is making this decision and no one else. From the physician's perspective, there comes a point at which the ethical role should shift from curing the patient to relieving their suffering.

The con side opened with an appeal to emotion, singing a brief song in Italian, before relating the story of a cancer patient who had gone through treatment once already, but had a recurrence of her cancer. She had to make a choice whether to go through it again, knowing that it would be hard and would be unlikely to give her significantly more time to live, or to opt for palliative care. She ultimately decided to accept her fate and let death come as it would. Her family had sung the song at her bedside as she died. The pulmonary physician asked why should patients need assistance hastening their death, rather than just letting death come?

In looking at the similar legislation in Oregon, she noted that the reasons why people opted for assisted suicide predominantly had to do with future-oriented, existential suffering (e.g., loss of bodily control, loss of autonomy/dignity, inability to engage in activities), rather than immediate concerns, like pain. Choice, she said, involves shared decision-making and informed consent, but she questioned whether patients could truly exercise informed consent without a mandatory psychiatric evaluation. Perhaps with extended conversation, the patient may see that there are reasons to live until death comes naturally. A big problem, in her opinion, was that the law would not require a psych eval, but it seemed she wanted a much more extensive psychiatric relationship than what is necessary to determine whether the patient is mentally capable of making such a decision.

She also worried about the loss of control of the prescribed medications once the patient took them home. There would be no way to ensure that the meds would remain in the possession of the patient, and if the patient changes their mind, how do we know whether a family member won't put the meds in the patient's food anyway?

Another objection was that the law would change the role of the physician from healer to killer, and that this would start a slippery slope to other forms of euthanasia (e.g., active euthanasia, where the physician would actually administer the lethal drugs, for example in the case of an ALS patient who is unable to self-administer the drugs). Finally, as the moderator indicated that her time was up, she mentioned that there were no objective criteria for the physician to judge whether the patient was suffering enough or not.

Both speakers were allowed to make closing statements. The anesthesiologist reiterated that this was about patient choice, and that, too often, physicians assume that they know better than the patient what is best for the patient; that may not always be the case. He suggested that those who are interested should watch How to Die in Oregon, a documentary following several terminally ill patients as they decide whether or not to take their deaths into their own hands. The critical care specialist worried that the law would not have enough oversight built in, and that there was potential for abuse. She worried that, if their attending physician deems them mentally unfit to make such a decision, patients might go "doc shopping" until they find someone who will prescribe the medications for them.

One attendee asked if there were any situation in which the specialist would feel this law would be appropriate. She replied that there was not, because of the wide array of other options that "we have used for millennia". Physicians are expected to respect patient autonomy, she said, not worship it. Again she asked "who are we to determine which lives are worthy of life and which aren't?" And then she threw her argument away by violating Godwin's Law, comparing this judgment to Nazi physicians, quoting "Lebensunwertes Leben" ("life unworthy of life"). At the start of the Q&A, she had asked that the projection screen be raised, revealing a painting of the first use of ether, and now she pointed to it to emphasize the role of healer, rather than killer.

The anesthesiologist responded by acknowledging that the actions of the doctors in Nazi Germany were a shameful mark upon the medical profession, and that physicians were some of the most enthusiastic supporters of Hitler. But, he said, conflating this law with the Nazis is a great injustice. I agree, especially since she kept speaking of the "physician's judgment", but this is all about the patient's choice. The patient is the one judging whether it is better to live or die, not the physician.

I had a chance to speak with them afterward and suggested that if ever she should discuss this proposed law again, the critical care specialist would do well to avoid Nazi analogies. She admitted that it wasn't a wise move, but questioned the anesthesiologists assertion that doctors were highly supportive. Instead, she argued, it was a gradual, step-by-step development. I asked blogging friend who has studied the Holocaust quite extensively who was correct. He confirmed that German physicians were, indeed, exceedingly enthusiastic and ready supporters of the Nazi Party.

Overall, my impression was that the critical care specialist's position was extraordinarily weak. She resorted to appeals to emotion, slippery slope fallacies and argumentum ad Hitlerum. She also seemed to be fixated on a misunderstanding (or misrepresentation) of the role of the physician under this law, if it were to be passed.

Death is not an easy topic for most people to talk about, let alone think about. But I think that this law, or something like it, is needed. I recall hearing the argument that "any life is better than no life at all" (which, IIRC, was also cited in a Supreme Court case...but I could be remembering wrong). Yet that, to me, is something that only the individual can answer for themselves. If a patient is of sound mind and is capable of making an informed decision for how they wish to die, whether by disease or by their own hand, then that is their own choice. And those who are ready to go and truly want to follow through with it will find a way. Physician-assisted suicide gives them the tool they need to control when, where and under what circumstances they wish to die. Certainly, there are other options for the truly determined, but they are not all certain, nor are they necessarily without risk to others.

I do admit that the con arguments included two issues that first gave me pause when I read the ballot question. First off is the matter of the psychiatric evaluation. The law only requires it if either the attending or consulting physician feel that it is warranted. Not every physician will be able to determine whether a patient is mentally capable of making this decision. But when it comes to making an informed choice, we don't always require a psych eval. For example, many (most?) clinical trials do not require potential subjects to be evaluated to ensure that they are capable of making the decision to participate or not; often it is left to the enrolling physician's opinion as to whether or not the person understands and is making a truly voluntary choice. I don't believe that an extensive, days- or weeks-long relationship with a psychiatrist or psychologist is necessary, but a brief consultation to determine the patient's mental state and capacity wouldn't be unwarranted.

Then there is the matter of the medications. There is, certainly, potential for loss of control of the drugs. An easy way around this would to have the patient, when they are ready, to schedule an authorized physician to bring the drug and oversee the administration. This would solve the problems raised above, but it would create an undue burden on both the patient and the health care system. Without more evidence that this would actually be a significant issue, I'm not convinced that the law, as written, would necessarily result in nefarious goings-on. Does this risk really outweigh the benefits of this law for the patients choosing to participate in it?

Ultimately, I feel that it would be better to vote in favor of the ballot question than against it. No one is forced to do it. Physicians who do not want to be a part of it can refuse to prescribe the lethal medicines to the patient. Patients who opt for this are encouraged to inform their family, but are not required to do so. There are reporting requirements to track all decisions, both oral and written, as well as registering the prescriptions, and penalties are established for anyone violating the law.

And to those who would argue against this from a religious viewpoint, I would simply say, who are you to judge? If it is a sin, then leave judgment for whatever deity you believe judges us when we die.

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