COMMENTARY

In Defense of Physician-Assisted Dying

Arthur L. Caplan, PhD

Disclosures

February 08, 2017

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Editor's Note: Arthur Caplan, PhD, interviewed Howard Grossman, MD, as part of the Medscape video series Both Sides Now. The original video, "Should Physicians Help Terminal Patients Die?" presented both pro and con points of view.

Only a portion of Dr Grossman's interview could be included in the video because of time constraints. Here, we are posting the interview in its entirety. In the coming weeks, we will post a discussion with Dr Farr Curlin, who was interviewed in the original video and is opposed to physician-assisted dying.

Arthur L. Caplan, MD: I am quite pleased to speak with Dr Howard Grossman, who is an internist in New York and New Jersey. He has an extensive practice in the area of HIV/AIDS and LGBT medicine, and was a pioneer in those domains of medicine. He also was active in a very important lawsuit that tried to establish a right to die at the federal level. Thanks for joining me today.

Howard A. Grossman, MD: Thanks for having me.

Dr Caplan: Many folks are trying to work out the best argument for permitting physician-assisted dying. If you asked yourself, what is the single most important reason for making this available and legal to my patients, what would it be?

Dr Grossman: I believe there are several big issues involved. One important point is that we are talking about mentally competent people who have been given a terminal diagnosis. This usually means that they have less than 6 months to live, with all the caveats about making those kinds of predictions. We are allowing people to make their own decisions about how they spend that end-of-life time. We already have established the right to withhold hydration and nutrition—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 that to happen. Furthermore, physicians and other practitioners are the gatekeepers for the medications. We have that responsibility.

Dr Caplan: You are needed in that regard. Would you say the key reason for legalizing assisted dying is to respect patient choice?

Dr Grossman: Absolutely. These are mentally competent people who know what they are doing, and they are making a choice about it.

Dr Caplan: Some people would say, "Wait a minute. Physicians are supposed to 'do no harm.'" Some may interpret those words to mean we are not supposed to kill. Maybe the patient wants it, but is it consistent with medical ethics to be involved with this?

Dr Grossman: No doctor should be forced to participate. That must be very clear, and it is clear in every law that has been passed so far. Thus, the physician and the practitioner must have the right of conscience.

But no, I do not believe that it violates the oath to do no harm. I believe we do harm to people when we force them to go through the dying process because somehow we think it is a beautiful thing. I believe it is the individual's choice.

Dr Caplan: Let me ask you a personal question. You can answer it from your own experience or from another's. Do you know people, physicians, who have been asked to assist to hasten death? Has that ever happened to you? Is that an experience you have been through?

Dr Grossman: It has definitely happened to me. I believe it has happened to most physicians. How people deal with it is difficult and personal.

Certainly, working as I did in the field of HIV/AIDS during the darkest days of the epidemic, we saw all these young people who were clearly terminal. They were on the road to death, and many times they experienced horrible deaths. This was not necessarily because they were in pain—they received pain medications—but it was horrible to put people into a coma with large doses of pain medications in order to keep them pain-free.

Dr Caplan: Some of my colleagues on the emerging palliative care side of the ledger may say, "Maybe you needed that in the '80s, or the early '90s. But we get it now. We know how to afford a person a dignified death. We can offer them hospice. We can fine-tune our medications. They do not have to be in pain." What is your response to that?

Dr Grossman: No one would advocate more strongly for palliative care and hospice than I would. I believe that is very important. I believe the choice to end your life early when you are terminally ill should be a last resort, after everything else has been tried.

Dr Caplan: Would it be fair to say that you do not believe palliative care and that mode of dying is necessarily for everyone?

Dr Grossman: Exactly. We have been hearing this argument from the palliative care people since the 1990s. This is nothing new. In the '90s, they said they had it all under control. Now, the argument is that if only palliative care was funded sufficiently, so that every medical student could understand how to provide palliative care, and if we were in there with everything the patient needed, then we would not need assisted dying.

Dr Caplan: I want to shift slightly. You have debated a lot of folks. You were involved in a key court case about this. What was that experience like, battling in federal court about a constitutional right to have assistance in dying? What made you get into that?

Dr Grossman: I got a call from Larry Kramer, who was one of the founders of the Gay Men's Health Crisis (GMHC) and the AIDS Coalition to Unleash Power (ACT UP) and who wrote the play, The Normal Heart. Larry asked me whether I knew anyone who would do this. And I said sure, I'll do it. Why not?

I brought a patient who did not live through to the end of the case. It was a very interesting experience, because we ended up winning in New York State. I have the front page of the New York Times where it was reported.

Then we went to the Supreme Court, and we lost. The Supreme Court did not find that we have a constitutional right to die. The court sent it back to the laboratory of the states, as they often do, and what has happened in the past 20 years is that various states have passed laws recognizing and allowing the right to die.

Dr Caplan: When you talk to critics, do you believe that if you scratch the surface, their opposition, their ethical concerns, are actually a debate about religion?

Dr Grossman: Very often, when I have had this discussion with people, I do believe their objections are religiously grounded, and that should be respected. They should be able to practice in the way they believe is right, based on their religious beliefs. But they should not impose those beliefs on everyone else.

Dr Caplan: If you look at Oregon, Washington, Vermont, and now California—these states that have legalized assisted death since the court battles—they have put a lot of protections into their laws. Patients must be determined to be terminally ill by two physicians, there are two waiting periods, patients must request it in writing, and physicians must report an assisted death to the authorities. There are a variety of safeguards.

Dr Grossman: And remember, the person must self-administer the lethal dose of medication.

Dr Caplan: You have to take the pill yourself. Do you believe those safeguards are adequate?

Dr Grossman: Yes,I believe they have been adequate. I do not recall any cases of abuse. What they have found in Oregon is that roughly one third of people who are prescribed a medication for this do not use it at all. They get the pills, and they feel empowered and relaxed. Whatever they choose to do as they approach death is their choice. But they feel comfortable because they know they have the option; it is in their hands and no one else's.

Dr Caplan: I have heard it said that legalization might actually have prevented suicides.

Dr Grossman: That is a good point. When you think about the way people have chosen to end their lives when they are terminally ill—a shotgun to the head, suffocating themselves, jumping out of windows—we have heard one horror story after another over the years. Why should someone have to do that? It makes no sense to me at all.

One of the most interesting debates I got into back in the '90s, around the time of the Supreme Court case, was at an event in downtown Manhattan. I was debating a woman who was involved in palliative care, and she was very frustrated with me. Finally, she yelled, "I don't understand why doctors have to be involved. If those people want to die, why can't they just put their heads in the oven?" And I thought, okay, that is the argument.

Dr Caplan: Jack Kevorkian was a believer in suicide on demand. He did not go along with these limits and restrictions. So what if someone says that what they are worried about is opening the door to people who are not terminally ill rushing through?

Dr Grossman: These laws are written for the terminally ill, and to qualify, the patient must provide evidence of being terminally ill. Dr Kevorkian was one of those people who explodes barriers, and that was his strength. But his weakness was that he did not do things legally. He did not follow any kind of guidelines.He was a one-man show. No one was looking over his shoulder.

All of these states where end-of-life choices are allowed are heavily regulated. That is how we protect people, and I believe people should be protected.

Dr Caplan: Let me push a little more. In Holland and Belgium, there appears to be a shift. They are not restricting assisted death to those with terminal illness. They are including people with irremediable suffering, perhaps psychiatric, perhaps a disability. What is your attitude about what they are up to?

Dr Grossman: That is euthanasia. My personal feeling is that people should have options, but I believe there is a lot of room for abuse when you start allowing other people to administer the drugs, and when you begin working with psychiatrically disabled people. But this practice in other countries contributes to the problems we have here. Many of the opponents of assisted dying conflate euthanasia with a patient's own choice to self-administer a lethal drug.

Dr Caplan: And administer it deliberately. In part, the opposition may be related to people being fearful that we are going to slide down the slope to euthanasia if we open up this possibility, as voters have done in Washington, Oregon, and elsewhere.

Dr Grossman: But I believe we have the evidence to show that does not happen when you have a regulated system.

Dr Caplan: Here is something I hear all the time: What if you select death, and it turns out that the cure was just around the corner? You got shortchanged. You did not realize that the next week, the precision medicine folks would be 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 of mine, back in the late '90s, when HIV therapy changed. This was a man who had had AIDS since the beginning of the '80s, and by the late '90s he was quite ill with multiple illnesses—lymphomas, cytomegalovirus retinitis, a bunch of other problems. He was taking scores of drugs.

Then the new antiretroviral cocktails came out. And he was one of those people who had a Lazarus effect. Previously, he had been in favor of the right to die. He lived another 5 years. I remember saying to him, "John, you came back. You talked to me about ending your life back in 1995, before all these new drugs. How would you feel if you had done that?" He said, "If I had chosen to do that, at that point it would have been the right choice and I would have made it anyway. I am glad I am still here, but that would have been the right choice for me. Nobody else gets to decide that."

Dr Caplan: In some sense, you have to choose with the hand you are dealt.

Dr Grossman: Exactly.

Dr Caplan: I do hear people saying, "I am dying, and we're spending the family fortune on me. I would like to see my grandchildren go to college, or I would rather my kids bought a new house, or paid off their mortgage. I do not want to live if I am bankrupting others." In one sense, that is noble, but in another sense, it seems like a bad reason to hasten your death. In that case, it is not about you, it is about the impact you are having on others. How do you respond to that kind of argument?

Dr Grossman: Actually, it is about you, the patient, because you are making a decision to protect your family in some way. It is an interesting argument. But face it: We are talking about people with less than 6 months to live. The economic impact is not going to happen then; the economic impact occurred when they first got sick, and for all the years they were being treated. Whatever impact that last few months has will be minimal.

Dr Caplan: Let me wrap up my questions with a different kind of "slope" concern. There are people who may have amyotrophic lateral sclerosis (ALS), [or] they may become demented, which may be a consequence of terminal illness, but they cannot ask for help to die. Should others be able to ask for them?

Dr Grossman: That is not the case right now. We need to begin by allowing competent people who can self-administer to do it. Right now, we say that if a person is demented and cannot make a decision for themselves, then no, you do not get to do that for them. If you are in a coma, you cannot participate.

Dr Caplan: Should the line be held there?

Dr Grossman: It has to be held there for now, until we have more experience and better understand how this works. I believe it makes sense to hold the line there. We should never cross that line for people who cannot make the decision themselves. There may come a time when people make the decision before they become incompetent and we have a legal, living will type of situation.

Dr Caplan: Will more states enact this kind of legislation?

Dr Grossman: Definitely. California just voted to approve this. In New York, a bill before the New York legislature was introduced recently that we hope will have a chance for passage, and we hope the governor will back it.

Dr Caplan: Thank you for joining me, Dr Grossman. You have shed light on a contentious [and] tough, but important, issue, and I very much appreciate your insights.

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