Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient's death?
Hi. I'm Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.
Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are "incompatible with the physician's role as healer." The Death with Dignity Act in Oregon was implemented in 1997. Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.
We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.
We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.
'Part of Our Job to Help People Die Better'
Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.
Timothy E. Quill, MD: I am glad to be here. Thanks for having me.
Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?
Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language "physician-assisted dying" rather than "physician-assisted suicide." Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.
Dr Caplan: When you say "mental illness," do you mean depression?
Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.
Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn't everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, "Why are we even having this discussion about assistance with dying if we have palliative care?"
Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, "What makes it so unacceptable? What is the worst part? Tell me more, tell me more." Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.
Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn't commit harm by assisting in dying?
Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.
Respecting Patient Choice
Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let's speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.
Howard Grossman, MD: Thanks for having me.
Dr Caplan: Let's get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?
Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.
Dr Caplan: You can refuse all life-preserving interventions.
Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.
Dr Caplan: Would you say that the key reason is to respect patient choice?
Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.
Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?
Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.
Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?
Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.
Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn't realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?
Dr Grossman: I think about a patient I had when this came up. In the late '90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the '80s. By the late '90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, "John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?" He said, "If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that."
'Despair May Be Temporary, but Death Is Permanent'
Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let's hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let's speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.
Maurie Markman, MD: Thank you. I am glad to be here.
Dr Caplan: Let's get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?
Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient's despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn't something reversible that would lead them to change their minds.
Dr Caplan: Just to emphasize, it is the reversibility of their psychological state.
Dr Markman: That is correct. Again, this is an example and certainly an example in the cancer domain, which is my experience. A patient could have been taking a tremendous amount of pain medications. They are not working and they say that nothing is working. I accept that. However, it could be that there is a single anatomical lesion that has not been appreciated or has not been approached. An interventional radiology approach or a surgical approach might be able to relieve that pain. If that pain were relieved, that could change the patient's psychological despair that led them to say, "I want to end my life."
Dr Caplan: What do you say to the advocates of physician-assisted dying? What do you say to the patient who says, "I understand that you can manipulate this and manipulate that, but I am dying and I do not want to go through all of that. I would rather be in control of how I die. I know that you could do this or sedate me or block this. I do not want to go through all of that."
Dr Markman: It is their right. It is as simple as that. Again, as a physician, I would see my role as an advisor, no more than that. If someone were to say that to me, I would say, "I accept that. Did you consider this? Did you consider that?" But of course, I am not a psychologist or a psychiatrist. It is also not for me to decide right or wrong. As a physician, I can voice an opinion. I can advise. I can even go to a family member if I think that there may be some element that just doesn't make sense to me, based on objective data. In your example, the patients want to be in control, but it may be a potentially curable cancer, let's say. There may be a concern that we are not getting through to them. My role in that is not to tell patients that they are wrong; my role might be to ask whether there is another way of approaching this that they're not hearing. If the answer is that this is their decision, it is their decision.
Making Death the Goal 'Is the Antithesis of Medicine'
Dr Caplan: Dr Markman has brought up some very thoughtful and provoking points. Now we will speak with Dr Farr Curlin, a physician and an expert in palliative care at Duke University. He is the Trent Professor of Medical Humanities and also works in the Center for Bioethics, Humanities, and History of Medicine at Duke. He is certainly one of the nation's leading experts on end-of-life care, and he has done pioneering work in integrating theology and healthcare. Welcome, Farr.
Farr A. Curlin, MD: Thank you.
Dr Caplan: Let me begin by asking you a straightforward question. You have a lot of experience in palliative care. What do you think is the key reason to oppose physician-assisted dying or physician-assisted suicide?
Dr Curlin: The main reason physicians should oppose physician-assisted suicide is that assisted suicide directly contradicts the purpose of medicine. It directly contradicts physicians' long-standing profession to maintain solidarity with those who are sick and debilitated. It is not just about medicine. I think it is the antithesis of medicine.
Dr Caplan: How do you respond to those who say that part of their mission as a physician is to relieve suffering and that part of their mission is to listen to their terminally ill patients— that if they want assistance in dying, it is consistent with a physician's ethical obligation both to relieve suffering and to honor their wishes?
Dr Curlin: Relieving suffering is obviously an essential aspect of physicians' work, but if we have no other objective criteria to decide what suffering we are obligated to relieve and what suffering we are not, then there is literally no boundary on our use of medical technology to achieve things that people want. For any conditions that people suffer from, they can ask that we take them away.
Dr Caplan: We have doctors contacting us with this kind of question. They say that, certainly, we don't want to be involved with children or psychiatric patients, but for those who are at the far end of dying, in the final throes of death with their MS overcoming them or their parkinsonism overcoming them, those who are in a stage of dying that is imminent, not even 6 months away but days—is there no relief, no mercy to be offered by hastening their death even at that point?
Dr Curlin: Patients in that situation are taken care of. Scores are in that situation. Without ever making their death our goal, we can treat those symptoms with powerful medications—as much as they need to get the symptoms relieved, whether it is choking on their secretions or gasping for breath or being in pain. If, as a side effect, the medication hastens their death, then of course physicians can still do that, and they have done that for centuries under what has been called the rule of double effect. It has been an important heuristic for guiding us. We do not make the death a part of our plan. We make relief of those health-diminishing and health-crushing symptoms our goal. We work toward it as hard as we need to get it done.
The Key Points
Dr Caplan: So, where is all of this headed and what does it mean for physician-assisted dying? Here are the key points that we have heard in today's program:
On the pro side, assistance in dying relieves suffering in terminal patients who are in pain. It enables ill patients to have some control over their life and death. Many consider this merciful and a part of what compassionate care is for patients. Patients with little time to live may want their suffering to end on their terms.
On the con side, physicians are enjoined against doing harm. Many believe that assisting in dying is harm. Some worry that there is a slippery slope, that it is going to become too easy for patients to commit suicide, not because they are terminally ill but because of depression or other reasons. Some conditions may actually turn out to be treatable. Death is not reversible, and some religions consider suicide in any manner a sin.
Here is my take. The issue of physician-assisted death is clearly going to remain a divisive topic for the foreseeable future, but I think we are going to see more states move to legalize it. The momentum is there. I think the practice is going to spread around the United States.
I hope that this program has given you some further insight and information so that you can make up your own mind about the subject. I am Art Caplan from the NYU Langone Medical Center on behalf of Medscape. I hope to see you next time on Both Sides Now.
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Cite this: Arthur L. Caplan, Timothy E. Quill, Howard Grossman, et. al. Should Physicians Help Terminal Patients Die? - Medscape - Aug 25, 2016.