Maryland Physician Loses License Over Assisted Suicide

January 12, 2015

A physician who holds a patient’s hand at a time of crisis usually garners admiration.

However, the Maryland State Board of Physicians last month ruled that when Lawrence Egbert, MD, clasped hands with six individuals as they asphyxiated on helium, he was helping them commit suicide — a criminal act in that state.

For this and related reasons, the medical board last month stripped the 87-year-old retired anesthesiologist of his medical license. The story of Dr Egbert, who has appealed the decision, is a twist on the nationwide debate about physician-assisted suicide, which is explicitly legal in Oregon, Washington, and Vermont. There, a physician is allowed under strict conditions to prescribe a lethal drug to a mentally competent patient judged by two physicians to be terminally ill — that is, with only six months to live in all likelihood.

That approach differs sharply from the modus operandi of the Final Exit Network (FEN), a group that Dr Egbert belongs to. This national organization helps individuals who have excruciating condition such as Alzheimer's disease or amyotrophic lateral sclerosis (ALS) end their lives even though they may not be terminally ill.

The method of choice is helium gas released in an airtight hood over the person's head. FEN assigns such an individual — referred to as a FEN member — one or two "exit guides" who rehearse suicide by helium and then attend the actual death. Exit guides, sometimes in tandem with a friend or relative, will hold the FEN member's hands to offer comfort.

The Maryland State Board of Physicians said that by holding hands, Dr Egbert also intended to keep the FEN member's hand from involuntarily jerking and knocking off the helium-filled hood, aborting the suicide. Dr Egbert agrees that was the case, but Frank Kavanaugh, PhD, a member of FEN's advisory board, told Medscape Medical News that "it's not our policy to keep people's hands still."

Dr Egbert, who has a soft voice and a light-hearted laugh, said he has attended some 100 self-willed deaths across the country.

During those events, "I'm thinking to myself, 'It's a blessing; their suffering has stopped,' " he said in an interview with Medscape Medical News.

Considered by some the successor to "Dr Death" Jack Kevorkian, Dr Egbert has not been charged with any crime in Maryland. However, he has confronted the law more than once. He was arrested at gunpoint in his home in Baltimore, Maryland, and charged with helping a Georgia man with cancer kill himself, which was against state law. However, the state supreme court later ruled that Georgia's law against assisted suicide was an unconstitutional abridgement of free speech, and Dr Egbert was never tried. An Arizona jury acquitted him of manslaughter in a similar case there.

He awaits trial in Minnesota for allegedly breaking that state's law against assisting in a suicide. Court documents suggest that this case may hinge in part on whether a jury believes that Dr Egbert was not only an adviser to a 57-year-old woman with chronic pain who put on the helium hood, but also an active participant by restraining her hands. FEN is paying his legal bills.

"I liken him to Jack Kevorkian in that he is really an out-front kind of person in what he does and believes in," said FEN's Dr Kavanaugh, a former professor of medicine and public affairs at George Washington University Medical Center. "He puts himself on the line. And he keeps his sense of humor all along."

The Case Against Dr Egbert

The physician with the jaunty white beard and moustache has been a risk-taking activist since he marched against the Vietnam War in the 1960s. He said he has worked with Doctors Without Borders as recently as the turn of the century, when his clinical career came to a close. Those missions took him to Kosovo, Lebanon, and Sri Lanka. Dr Egbert was FEN's medical director until 2010. He no longer serves as an exit guide.

He keeps a hand in medicine by examining asylum seekers who claim to have been tortured on behalf of immigration lawyers, he said. "I look for physical and psychological scars."

He freely makes concessions to his advanced age. In the voice message on his telephone answering machine, he asks callers to speak slowly "because I'm getting a little hard of hearing."

The Maryland medical board revoked his license on December 12, 2014, on account of "unprofessional conduct in the practice of medicine" while he was FEN's medical director. In that role, he obtained and reviewed the medical records of those who applied for FEN membership and assisted suicide (assisted dying and aid in dying are preferred expressions in the right-to-die movement). He dissuaded one distraught applicant from ending her life by suggesting a stronger dose of the morphine she was taking, according to medical board records.

The board focused on Dr Egbert's participation in the suicides of six individuals, none of them terminally ill. Their medical conditions ranged from Parkinson's disease and chronic obstructive pulmonary disease to "worsening monopolar depression" in the case of an 87-year-old woman.

"The idea these people aren't suffering is wrong," Dr Egbert told Medscape Medical News, referring to the depressed, particularly those whose condition is intractable. He said the question of accepting such individuals as FEN members once roiled the organization, prompting one of its presidents to resign in opposition. FEN, officially at least, does not countenance helping individuals like an 87-year-old woman with monopolar depression. One of its criteria for FEN membership, as stated on the group's website, is that the person "must have an irreversible, physical medical condition which causes intolerable suffering."

"Depression is trickier," FEN's Dr Frank Kavanaugh told Medscape Medical News. "We try to make sure people are mentally competent and rational and not suffering from a temporary depression that could be helped by medication and therapy."

The board said that Dr Egbert's involvement with the six FEN members constituted the practice of medicine in part because he considered them his patients and reviewed their records. He also held himself out as a practicing physician to FEN members as well as other physicians when he made record requests. Dr Egbert countered that his actions lay outside the scope of medical practice, however, because he was not diagnosing or treating any medical condition.

At the same time, he believes that the work of an exit guide should legally fall into the practice of medicine, or some other helping profession, and be regulated as such. He anticipates making these arguments in his appeal of the medical board decision, which he filed in a Maryland state court last week.

The board faulted him for "unprofessional conduct" on several counts. Dr Egbert, it said, acted deceptively when he removed the helium tanks, tubing, and hood from the death scene, which "not only hindered police investigations, but also caused other physicians and medical examiners to list the cause of death incorrectly on the patient's death certificate."

Dr Egbert told Medscape Medical News that exit guides routinely recommend to relatives and friends attending a "death event" that they should remove the equipment afterwards. "A lot of times, they don't feel like it," he said. "If they were too upset to do it, we would."

The Maryland medical board also said that Dr Egbert and FEN dispensed with safeguards adopted by states that have legalized physician-assisted suicide. One is a mandatory psychiatric evaluation of the person seeking to end his or her life to ensure the decision is rational, according to the board. The Oregon law, the first in the nation and the template for others, requires such an evaluation if either the person's attending physician or a consulting physician suspect that a psychiatric or psychological condition is impairing the person's judgment, which would disqualify him or her.

Another safeguard Dr Egbert neglected, said the board, is that the person seeking assisted suicide has a terminal illness and only six or so months to live. Dr Egbert, however, doesn't put much stock in a six-month prognosis.

"The ability to predict that someone will die within six months is very difficult," he said. "Any physician I know would say the error rate is huge."

In addition, the six-month cut-off leaves people with conditions such as ALS living in misery for months or years on end. "That disease is about as horrible as I can imagine," he said.

Then there is the hand-holding, meant in part to prevent the FEN member from knocking off the helium-filled hood accidentally. The board said "holding down the patients' hands" violated the prohibition against physician-assisted suicide found in the Code of Ethics of the American Medical Association as well as a Maryland statute that forbids anyone from "knowingly participating in a physical act by which another individual commits or attempts to commit suicide."

Dr Egbert said he didn't exactly hold down anybody's hand. He said he asked permission of FEN members to hold their hand, saying that he would take their pulse and make sure they didn't bump the hood if they twitched involuntarily as they succumbed to the helium. Other than that, their hands might move around.

The purpose of hand-holding was not to prevent the FEN member from ending the suicide attempt because of a change of heart, he insists. The person can simply ask those in attendance to remove the bag, Dr Egbert said, adding that his or her voice would sound as squeaky as the cartoon character Donald Duck's under the influence of helium.

Exit guides, he said, repeatedly ask FEN members throughout the process whether they still want to end their lives. FEN distinguishes between someone who has carefully thought through the issue over weeks and months and someone who is temporarily depressed, such as a teenage boy who gets dumped by a girlfriend. "I can still remember that," he said, chuckling.

"Nobody does this in a frivolous manner."

Two Competing Visions of Assisted Suicide

FEN is not the only organization fighting for Americans' right to die. Compassion and Choices is an end-of-life advocacy group that has pushed for physician-assisted suicide laws like those in Oregon, Washington, and Vermont.

Dr Egbert said he belongs to that group, too. The laws that it has helped pass are a good first step toward full end-of-life rights, he said. "They're doing a good job."

In a statement issued to Medscape Medical News, Compassion and Choices said it could not comment on the decision by Maryland to revoke Dr Egbert's license "because we do not have any knowledge of the facts of the case."

The group contrasts its support of "the medical practice of aid-in-dying" through medications with FEN's "non-medical method (helium and plastic bag) of independent self-deliverance." In addition, Compassion and Choices supports the right of only terminally ill, mentally competent individuals to receive aid-in-dying while FEN extends it to "adults who have a mental or chronic condition" as well. The group said its consultation services "adhere to the letter of the law in every state," leaving unsaid the legal wrangles that FEN has faced.

FEN comes across as a collection of renegades compared with Compassion and Choices and its play-by-the-rules rectitude. "They consider us a political liability," said Dr Egbert.

The two groups share a history that gives them more in common than Compassion and Choices suggests in its statement. Their family tree goes back to the Hemlock Society, founded in 1980 by journalist Derek Humphry to promote voluntary euthanasia. "The right to choose to die when in advanced terminal or hopeless illness is the ultimate civil liberty," his website states. Humphry's 1991 book titled Final Exit amounts to a manual on "self-deliverance and assisted suicide for the dying," as the cover puts it.

The Hemlock Society morphed into a group called End-of-Life Choices that later merged with another group to form Compassion and Choices in 2005, according to its website. While Compassion and Choices campaigned to legalize physician-assisted suicide for the terminally ill, other former Hemlock members wanted to help the dying without waiting for the laws to change, said FEN's Dr Kavanaugh. "Compassion and Choices is a good cause, but people are suffering today. We need to respond to them." End-of-lifers who thought like that, he said, formed FEN. Derek Humphry heads up its advisory board, which includes Dr Kavanaugh.

FEN bills itself as the only organization that will support individuals who are not terminally ill as they seek to hasten their death. "Final Exit Network will serve many whom other organizations may turn away," its website states, a veiled reference to Compassion and Choices.

"People Think I'm a Saint"

A Washington Post article in 2012 called Dr Egbert "the new public face of American assisted suicide," succeeding the late Jack Kevorkian. Both FEN and Compassion and Choices have mixed feelings about the pugnacious pathologist whose advocacy of assisted suicide went so far as injecting ALS patient Thomas Youk with a lethal drug himself. Kevorkian videotaped the act, shared it on the CBS television show 60 Minutes to provoke a legal response, and got one. He was convicted of second-degree murder and served 8 years in prison.

At the time of his death in 2011, Compassion and Choices President Barbara Coombs Lee told Medscape Medical News that Kevorkian had helped pave the way for legalizing physician-assisted suicide because "he highlighted the severity of the problem." At the same time, Lee said, Kevorkian had stepped over the line from assisted dying to euthanasia by personally administering a lethal drug to Thomas Youk.

"We don't think euthanasia is good public policy," Lee said in 2011.

Meanwhile, FEN published loving tributes to Kevorkian in its newsletter after his death. "I know he has the nickname Dr Death, but I call him Dr Compassion," wrote one retired Episcopal priest.

However, Dr Kavanaugh said that Kevorkian departed from FEN principles by actively taking the life of someone. "Larry Egbert has never done that," Dr Kavanaugh said. "That's what makes him different from Jack." Dr Egbert also said he has never been an active participant in an assisted suicide, contrary to what the Maryland medical board ruled on the matter of hand-holding.

The physician called the new Jack Kevorkian appears to accept the title.

"I think his work should be carried on," said Dr Egbert. "The difference between us is how we speak out. He was quite flagrant in his style, and I tend to be relatively quiet. I don't look for trouble."

Dr Kevorkian was pilloried in some quarters for aggressively pursuing his assisted-suicide agenda. He was called a madman, a monster, a murderer. So how does Dr Egbert feel about being a lightning rod in the end-of-life debate? Has he encountered any harsh judgments?

"I'm not used to harsh judgments," he replied. "People think I'm a saint."

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