Early this past June, the Annual Meeting of the American Society of Clinical Oncology (ASCO) included an ethics session featuring a point-counterpoint discussion, with audience Q+A, of “physician aid in dying,” or, as I think more accurate, “physician-assisted suicide (PAS).” Discussants were Dr. Timothy Quill, a palliative care specialist who is a past plaintiff in court cases seeking legal approval of PAS, and Dr. Daniel Sulmasy, an oncologist who is an outspoken opponent of PAS. Both have written extensively on the subject.
I missed the session but only now was able to review it on ASCO’s “Virtual Meeting,” available only to subscribers. I cannot summarize it fully but will just relay some observations from my listening. I will say that the session lived up to its billing as a “thoughtful discussion,” one that demonstrates just how far our thinking has come (wandered?) on this matter.
I think it important to say that, although I consider Dr. Quill an adversary, his presentation clearly demonstrated concern for his patients. Some of his noteworthy points:
- · Although he calls PAS a “last resort,” he includes it in the umbrella of palliative care measures, and claims that the same issues of potential harms arise with all of them. I’m not so sure; one can heavily sedate someone, not intending to kill him but accepting that risk (by the rule of “double effect”), and that is different from purposely helping that person kill himself.
- · He emphasized that more patients ask about PAS than actually go through with it. But he showed data from Washington state in which the numbers of the two were nearly identical.
- · Because of that, he is concerned that a refusal to discuss PAS with a patient could compromise the care of the patient by turning a deaf ear to the patient’s concerns—which, as well recognized, are typically around loss of control, not pain, at the end of life.
- · He voiced support for a conscience-based “opt out” by doctors opposed to PAS but said “that doesn’t take [the doctor] off the hook,” meaning not that the doctor must refer to a “PAS doctor,” if you will, but that the challenging task of caring for the patient remains.
- · Similarly, he commented that in about half of PAS cases in the US, the lethal prescription is written by a doctor with less than 6 months’ acquaintance with the patient. I understood Dr. Quill to say this is not a good thing, suggesting breakdown of longer-term physician-patient relationships precisely when those relationships are most critical.
- · He said that the legally-approved method of taking the prescription in Washington State is not easy. Recall the patient, not someone else, administered the prescribed drug, which is 100 capsules of secobarbital, opened by the patient one by one and dumped into applesause (or something similar), making a distasteful concoction. I couldn’t help being saddened just imagining someone following through on the grim task.
- · He said that, although we might want to get clean resolutions in all cases, the fact is that care of some patients is genuinely so hard that true relief of symptoms is not possible.
Dr. Sulmasy countered with a strong and classic argument against PAS as bad medicine and bad policy, following reasoning like what has been written previously on this blog by me and others, so I will not try to rehearse it fully here. He drew the distinction between providing medical care and actively helping someone kill herself. Further:
- · People looking at the Oregon or Washington experience to argue that the “slippery slope” is not real are ignoring the contrary data from the Netherlands and Belgium, where the practice has been in place longer, and where people are offered PAS for depression.
- · To those who object that “depression” does not apply to terminally ill patients who request PAS, Dr. Sulmasy countered that all too often treatable depression is not even sought by the physician, much less treated.
- · The logic and experience with PAS will eventually demand that it be offered to people who are not terminally ill.
- · Similarly, arguments based on autonomous choice will unavoidably be used to argue for actively killing people who can’t take a lethal prescription themselves, such as people with dementia or neurodegenerative disease, or children.
- · “Opt outs” are being forcefully opposed in Belgium and Canada.
- · He argued that symptoms are treatable in nearly all cases.
- · Perhaps most notably, to the point that “existential suffering” about loss of dignity or loss of control is paramount, Dr. Sulmasy argued for caring for the patient in the face of this, and not succumbing to PAS. In so saying, he commented that it is not part of the doctor’s calling to “relieve the human condition.”
Three questioners stood out:
One said that his main local hospice has announced it will NOT participate in PAS. He supported this, but worried it will “affect his ability to refer” patients who may want to explore PAS to that hospice. (Dr. Sulmasy commented that institutions as well as individuals should be free to opt out of PAS based on conscience.)
A second questioner, who said he consults and accepts PAS referrals in Oregon—aessentially arguing “somebody’s got to do it”—said that in his experience, many, many times the physician (oncologist) has not only failed to discuss end of life care at all with the patient, but has not even told the patient that the diagnosis is terminal. This was part of a longer comment saying that we should not condemn the short-term relationships between patients and doctors who write lethal prescriptions. This made Dr. Quill uneasy. He objected that “specializing” in PAS was deeply suspect ethically because “it would make [PAS] too easy, and this [palliative care] is not easy”
A third questioner suggested revising the Hippocratic Oath to remove any indication that doctors should not participate in PAS. After all, we don’t appeal to Apollo anymore, do we? (And, unspoken at the session, many medical schools have dropped the Hippocratic proscription of abortion.) But no, we should not! That’s the point! The Hippocratic tradition confirms the essential role of the physician as healer, not killer, and doctors in the 21st century should likewise affirm that principle robustly.