When should physicians provide a good death?

A recent New England Journal of Medicine (NEJM) Perspective by Deborah Denno, Ph.D., J.D., entitled “Physician Participation in Lethal Injection” (subscription or limited free access required) discussed physician involvement in state-sanctioned capital punishment by lethal injection. Some of the arguments for physician involvement in euthanasia (“a good death”) or Physician-Assisted Suicide (PAS) would seem to apply to some degree to lethal injection and is the subject of this blog entry.

For those without access, the article explored a recent Supreme Court rejection in Bucklew v. Precythe of a Missouri death row inmate’s appeal for protection from lethal injection under the Eighth Amendment’s prohibition of “cruel and unusual punishment”. In short, Russell Bucklew has a rare vascular condition making venous access both difficult and potentially more painful to use lethal injection as the means to execute him. It was argued that his medical condition necessitated at least medical training to guide the injection process, if not actual physician/surgeon training, such as possessed by an anesthesiologist, to provide the actual vein access for the lethal injection. In rejecting his appeal, the Court responded, in part, “the Eighth Amendment does not guarantee a prisoner a painless death – something that isn’t guaranteed to many people, including most victims of capital crimes.” The Court added that methods prohibited are those that “superadd terror, pain or disgrace to their executions”, though as the article points out, the Court does not specify as to how to test those limits, and left unanswered whether physician involvement was legally required to guarantee satisfaction of the Eighth Amendment.

The article discusses the fact that national medical associations generally strongly discourage their members from providing guidance for lethal injection. The American Medical Association’s (AMA’s) own amicus brief for the case listed above states that the AMA opposes capital punishment. The American Society of Anesthesiologists (ASA) takes a similar position opposing participation of its members in lethal injection. Both the AMA and the ASA agree that capital punishment is not the practice of medicine and the ASA goes further to challenge the Court to look elsewhere for any lethal injection skills.

Interestingly, both organizations are less precise on their position regarding physician involvement in euthanasia or PAS. The AMA sees PAS as causing “more harm than good”. The ASA has no official published position on PAS that I could find on their website. Their Statement on Palliative Care does not mention euthanasia or PAS. This is important, as there is a growing demand for physician involvement in euthanasia/PAS, the implication being that there is additional benefit with physician involvement in achieving a good death.

For the record, I have always believed that physicians are uniquely the worst choice for killing people under any circumstance as our training universally focuses on honing skills that avoid causing death to our patients. We are effectively trained at not killing and would therefore provide dysthanasia – a bad death. But, perhaps, I am mistaken. There is growing demand to involve physicians in actively and purposefully killing their patients, with many holding the contrary belief that physicians uniquely have the best skill set to provide for euthanasia – a good death.

So, even though Russell Bucklew failed to make a successful legal case for physician involvement in lethal injection, did he make a sufficient moral case? If physicians and their unique skills are necessary for euthanasia/PAS, are they not equally necessary for state-sanctioned execution, particularly given that the latter involves the non-voluntary death of an individual who is guaranteed Eighth Amendment protections, and especially given our inability to provide any scientific evidence that we are satisfying those protections?

If physicians really are the best at providing euthanasia, doesn’t moral justice demand we require a physician to similarly provide a good, physician-assisted, state-sanctioned, death (PASSD) despite the stated objections of the AMA and ASA? Anything less arguably opens the door for adding “terror, pain or disgrace” to the execution.

Physician-assisted suicide, euthanasia, and the World Medical Association

The World Medical Association (WMA) is cogitating on physician-assisted suicide. Their current statement, adopted in 1992, “editorially revised” in 2005, and reaffirmed in 2015, is as follows:

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.

WMA’s statement on euthanasia, adopted in 2002, and reaffirmed with minor revision in 2013, states

BE IT RESOLVED that:

The World Medical Association reaffirms its strong belief that euthanasia is in conflict with basic ethical principles of medical practice, and

The World Medical Association strongly encourages all National Medical Associations and physicians to refrain from participating in euthanasia, even if national law allows it or decriminalizes it under certain conditions.

Drama has been unfolding in recent months regarding these positions of the WMA. In October 2018, the Royal Dutch Medical Association (KNMG) and the Canadian Medical Association (CMA) together proposed that the WMA change its position to “neutrality.” This Proposed WMA Reconsideration of the Statement on Euthanasia and Physician Assisted Dying was retracted late in the process due to strong opposition.  The German Medical Association proposed a compromise of changes in the language. Those changes included “physician-assisted death” instead of “physician-assisted suicide,” and “physicians should not engage” in place of “unethical and should be condemned.”

The WMA decided to seek written opinions, and revisit the subject at the 2019 Council meeting. In a press release from 29 April 2019, the WMA Council announced that

It was agreed that policy work should continue on physician assisted suicide, augmented intelligence, violence against healthcare professionals and the patient-physician relationship.

With the next WMA Council and General Assembly scheduled for 23-26 October 2019 in Tbilisi, Georgia, observers should note the jockeying for position by various medical associations. It seems unlikely that those medical associations in jurisdictions where physician-assisted suicide or euthanasia are embraced would decrease pressure on the WMA. Yet we can hope that the World Medical Association will not succumb to such forces. After all, the WMA was formed in the shadow of World War II – a time when the raw wounds of incredibly inhuman acts by some humans against others had been recently seared into the minds of millions. The WMA needs to stay the course they set in 1946, for, to paraphrase George Santayana, those who do not learn from history are condemned to repeat it.

Physician Assisted Suicide, Again

Last month, I sat through a presentation on the ethics of Physician Assisted Suicide (PAS) in a local hospital.  I attended the presentation, not because I am unfamiliar with the arguments on the subject and ambivalent about my feelings on it, but because I wanted to observe how it was presented, what the reaction of the audience was to the presentation, and how it might affect my work as a hospital chaplain.

For some context, the state where I reside, Florida, does not have a PAS law on the books, nor, according to the “Death with Dignity” website, is it even considering one.

I found the presentation to be disappointing, in part because the participants talked past each other as if they were on a cable news program, repeating the typical talking points that have become so common over the years.  It was also disappointing because it used the classic example of a sad, horrible death story to advocate the use of PAS with the highly manipulative question, “You wouldn’t want your loved one to experience this, would you?”  No one ever seems to respond that we cannot build a law out of such experiences because hard cases make bad law, nor does anyone ever take the time to wonder what else could have been done to make the suffering patient more comfortable.  It simply is an elevation of human autonomy to a staggering height.

At the end of the presentation, the PAS advocate asked for a show of hands on people’s support/non-support of PAS.  I didn’t have the heart to count the hands, but the speakers said it was about 65%-35% in favor of PAS.  My worst fears had been confirmed.  After what I witnessed in that presentation, I have no doubt that we are headed full-speed ahead towards a civilization that will in some way systematically encourage its elderly, its weak, its sick, and its disabled citizens to make a “compassionate choice” and choose “death with dignity.”  Those of us who think otherwise are firmly entrenched in the minority.

I understand that I am not the first person to have had this experience, and in some ways I have anticipated this day for some time, but because I saw it so close to home, it still was somewhat shocking to me.   When filling out the seminar evaluation, I found the question, “How will apply what you have learned today to your current practice?”  I’m not sure what the reviewers thought, but my response was simple: “I will continue to advocate strongly against PAS, affirming God’s gift of life whenever and wherever I can.”

Do Polls about PAS Tell the Whole Story?

By many indications, support for the legalization of physician-assisted suicide [PAS] is increasing. On November 8, 2016 Colorado voters passed Proposition 106, “Colorado End of Life Options Act,” by a 65% to 35% margin, making Colorado the sixth state to legalize PAS, joining Oregon, Washington, Montana, Vermont, and California. The following question appeared in a 2015 Gallup poll: “When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patients requests it?” 68% of respondents answered “should” while only 28% answered “should not.”

That to which people are saying “yes,” however, does not always match the reality of the practice of PAS in the states in which it has been legalized. Note the wording of the question in the Gallup poll. The question pictures a medical situation in which: (1) The disease is incurable; (2) The patient makes a voluntary request; and (3) The patient is “living in” severe pain, which suggests constant, relentless, and untreatable pain.

Most likely, in my judgment, people are prompted by mercy in saying “yes” to PAS because they think that a large percentage—perhaps even a majority—of patients suffer unrelenting and untreatable pain, making PAS a compassionate option. If this is indeed what respondents are thinking, they are mistaken in large measure. Granted, pain is intractable and difficult to manage for some dying patients, but certainly not for the majority of patients, thanks to advancements in palliative care. Even the patients who avail themselves of legalized PAS tell us that. According to the official 2015 report on Oregon’s Death with Dignity Act, patients requested medical assistance in dying for these top three reasons: (1) Decreasing ability to engage in activities making life enjoyable (96.2%); (2) Loss of autonomy (92.4%); and (3) Loss of dignity (75.4%). “Inadequate pain control or concern about it” was in sixth place, mentioned by 28.7% of patients. Yet, even here, it is difficult to break down the percentage of patients who were actually experiencing inadequate pain control from the percentage of patients who were merely concerned they might. It seems likely that some patients request PAS on the basis of what they might experience in the future, not on the basis of what they are experiencing in the present.

Motivated by mercy, a majority of Americans are beginning to say “yes” to PAS. I wonder if the level of support would change if respondents realized that, in the vast majority of cases (though admittedly not in all cases), pain can be effectively managed. In no study that I’ve read has “relief from pain” been a top-tier reason patients give for requesting PAS in states in which it is legal. That to which respondents are giving a merciful “yes” does not seem to match the reality.

A Modest Proposal to Solve the Physician-Assisted Suicide Debate

Yesterday’s Chicago Tribune carries an editorial by Steve Chapman entitled “The Case for the ‘right to die.'” Aside from missing the central point of the whole question, Chapman does a creditable job of marshalling arguments and bioethicists to support his support for physician-assisted suicide. However, he does neglect the central point, which, of course, is that doctors do not and should not kill — including not giving patients a deadly drug with the intent that the patient will use it to kill themselves. This has been a central tenet of medical ethics ever since there were medical ethics, and for good reason. Doctors are no more able to wisely and ethically deal out death than anyone else. I write as a physician, and I can assure you that a strong background in biochemistry, pathology, pharmacology, genetics, bioethics, etc., does not give me the wisdom and ethical discernment to make the decision to intentionally provide someone with the means to intentionally kill themselves.

Thus, the dilemma: Chapman and many others think that when it comes to killing themselves, patients should be able to get whatever they want, and that doctors should help them; and most of us doctors and our various societies say that we won’t help patients get everything they want if it means they want to kill themselves.

Allow me to propose a simple, yet elegant, solution: Eliminate the middle man (or woman).

Let me explain: Chapman et al. want to help patients kill themselves, but doctors have a problematic ethical code prohibiting them from doing such. Doctors have no more expertise than anyone else at dealing out death. So, eliminate the doctors from the equation: instead of Physician-Assisted Suicide, let’s establish Newspaper Editor-Assisted Suicide. And for those bioethicists who have jumped on the bandwagon, let’s have Bioethicist-Assisted Suicide. And to make it all easier for patients who don’t have easy access to an editor or bioethicist, we can add Plumber-Assisted Suicide, Bank Teller-Assisted Suicide, or Cable TV Guy-Assisted Suicide.

The advantages of this approach should be readily apparent. Patients get what they want, doctors don’t get what they don’t want, and Chapman et al. get to carry out their good intentions unencumbered by centuries of ethical tradition, thought, and wisdom.

The Indignity of a Death with Dignity

The story of Brittany Maynard, a 29-year old newlywed who has been given the diagnosis of terminal glioblastoma, an especially aggressive brain tumor, has gone viral over the past week. Many know the story already, but it centers on her decision to end her life by taking an oral medication prescribed by her physician, who will be sitting at her bedside with her husband and other members of her family at the end, at a date she has selected to coincide with her husband’s birthday later this month. The details are chronicled in People magazine, which is significant because of the role the magazine plays as gatekeeper for what is to be considered culturally-normative, and because it is where you can see the heart-wrenching video she and her husband prepared to explain her decisions.

I will not attempt to mount a thorough rebuttal to her choice of physician-assisted suicide, one made to avoid the certain-suffering that will face her as cancer ravages her mind and body. Perhaps the best, most elegant response I have seen can be found here, the words of a fellow traveler on the awful road of terminal glioblastoma. Other responses, including a Matt Walsh blog and even a debate on the Blaze, offer great commentary as well.

But so much of what Brittany says needs to be answered by many more, those who have profound objections to what she is saying, because she is sharing this difficult and intimate season of her life for reasons of advocacy. She, her husband, family and doctor support the causes of the “Death with Dignity” movement with the organization “Compassion and Choices.” After her diagnosis, Brittany specifically moved to Oregon where the process of physician-assisted suicide (PAS) is legal. Within the People article itself, there are plenty of opportunities to see how semantics will be used in the future to argue for PAS.

Brittany makes it clear that, in her view, this is not suicide…she does not wish to die, but her life is to be taken from her by cancer and “it’s a terrible, terrible way to die.” I don’t disagree with the latter sentiment…I pray that it will not be the way I leave this life, either. But I believe that my life is not my own…I ceased believing it was long ago…and I have no authority to decide how I leave it. I trust a Lord who has never ceased to be my advocate for what is best for me, and I will trust that same Lord with my eternity. But those who attempt suicide, or succeed, rarely think that ending life is what they really want, but that the “terrible, terrible” pain they face makes death the better answer. If the pain (emotional or physical) would end, suicide would be unnecessary.

She addresses ethics: “I believe this choice is ethical, and what makes it ethical is it is a choice.” Again, I don’t want to be cruel to someone who is suffering in a way in which I have no way to relate, but this argument is both insipid and dangerous. It is the latter because it is supported by little ethical framework than that of radical autonomy. She believes that, because she can ostensibly change her mind at any time (and many pray that she will), all is right with her choice. Never mind that it seems unlikely that someone so committed to the cause as she will join many (nearly half) of those who sign on with the “Death with Dignity” provisions, getting prescriptions written…and never follow through. Perhaps she will not find herself as free as she thinks. As resources become scarcer, some with the “choice” will find other subtle (or not-so-subtle) pressures to follow through. Beyond coercion, “choice,” as an ethical paradigm, also fails to account for collateral damage to others.

Brittany has had a remarkable life in her 29 years. Her accomplishments, including climbing Mount Kilimanjaro, show someone who has been in control of her life. The beautiful photos attest to a young woman that seems to be dying in her prime. There is a sense that she fears the pain that accompanies death from a terrible disease, but the greater sense is that she will lose control. Pain can be controlled by medication; control of one’s fate, once lost, is irrecoverable.

Her final sentiments are spoken thusly: “I’m dying, but I’m choosing to suffer less,” she says, “to put myself through less physical and emotional pain and my family as well.” This last part makes me want to cry. I have no idea what her faith system is, but I see that it isn’t one that can find the redemptive value in suffering, in the “ministry of dependency” that comes from letting others love us well when we leave this life. I am not a vitalist; I don’t want to live my life for as long as possible and at all costs. But I do want to let my faith be revealed in the trust I place in God and the people with who I have been blessed to share my sojourn on this Earth. It’s a trust that means that as I lose lucidity and seem less dignified, I will know that my true dignity as a being created in the very Image of my God, one undiminished by a time of mental and physical incapacity that occurs before I pass into an eternity that bids pain and sorrow goodbye forever. The indignity of a rotten death pales in comparison to that inherent dignity. I wish Brittany that same knowledge.