Ethical Issues in Medical Oncology: Physician Aid-in-Dying

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  • Association of Northern California Oncologists Annual Meeting
    Tenaya Lodge at Yosemite
    Saturday, October 15th, 2005
    ETHICAL ISSUES IN MEDICAL ONCOLOGY: PHYSICIAN AID-IN-DYING
    Ernlé W.D.Young, Ph.D.
    Professor of Medicine Emeritus (Biomedical Ethics)
    Stanford University School of Medicine
  • In the time available to me, I would like to cover the following ground:
    1. To define exactly what we mean by Physician Aid-in-Dying (PAD)
    2. To review a brief history of the attempt to legalize PAD
    3. To look at the arguments against PAD
    4. To examine the arguments in favor of PAD
    5. To weigh the central arguments critically
    6. To consider data from the Seventh Annual Report on Oregon’s
    Death With Dignity Act
    7. To offer an ethical framework for making up one’s own mind about this contentious issue.
  • What exactly are we talking about when we use the term Physician-Assisted Suicide (PAS) or Physician Aid-in-Dying (PAD) (which I prefer)?
    1. We are NOT going to consider the activities of someone like Jack Kevorkian, a pathologist with obvious sociopathic tendencies meeting patients who wished to die for an hour or two, then hooking them up to one of his suicide machines in the back of his VW Kombi van.
    2. Nor will we be discussing active euthanasia as in the Netherlands, where it is now legal for physicians actively to terminate with lethal injections the lives of those who consider their suffering unbearable, usually in their own homes.
    3. We WILL BE talking about Physician-Aid-in-Dying as modeled on Oregon’s Death With dignity Act, as set out in California’s AB 654, proposed legislation to establish a process for a terminally ill patient to request that life-ending medication be prescribed by his or her physician.
  • Oregon’s Death With Dignity Act, on which AB 654 was modeled, requires that to request a prescription for lethal medications (which patients must self-administer), a patient must be:
    An adult (18 years of age or older)
    A resident of Oregon
    Capable (defined as able to make and communicate health care decisions)
    Diagnosed with a terminal illness that will lead to death within six months
  • Patients meeting these requirements are eligible to request a prescription for lethal medication from a licensed Oregon physician. To receive a prescription for lethal medication, the following seven conditions must be fulfilled:
    The patient must make two oral requests to his/her physician, separated by at least 15 days.
    The patient must provide a written request to his/her physician signed in the presence of two witnesses,
    The prescribing physician and a consulting physician must confirm the diagnosis and prognosis.
    The prescribing physician and a consulting physician must determine whether the patient is capable.
    If either physician believes that patient’s judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination.
    The prescribing physician must inform the patient of feasible alternatives to assisted suicide, including comfort care, hospice care, and pain control.
    The prescribing physician must request, but may not require, the patient to notify his or her next-of-kin of the prescription request.
    To comply with the law, physicians must report to the Department of Human Services (DHS) all prescriptions for lethal medications within 7 working days of prescribing the medication. In the summer of 1999, the Oregon legislature added a requirement that pharmacists must be informed of the prescribed medication’s ultimate use. Physicians and patients who adhere to the requirements of the Act are protected from criminal prosecution, and the choice of legal physician-assisted suicide cannot affect the status of a patient’s health insurance or life insurance policies. Physicians, pharmacists, and health-care systems are under no obligation to participate in the Death With Dignity Act.
  • 2. A Brief Chronology:
    1991—Washington’s Proposition 119, narrowly defeated
    1992—California’s Proposition 162, narrowly defeated
    1994—Oregon’s Measure 16, passed by 51/49
    1996—the 9th and 2nd U.S. Circuits Courts of Appeal rule that state prohibitions on P-A-D are unconstitutional
    1997—the Supreme Court reverses both the 9th and the 2nd Courts’ rulings, but leaves the door open to State ballot and legislative initiatives
    1997—Oregon’s Measure 16 reaffirmed by 60/40
    1998—Measure 16 becomes law in Oregon
    2004—Attorney-General Ashcroft’s move to criminalize the prescription of medicine that “will result in patients’ deaths.”
    (Ashcroft viewed physician-assisted suicide as a violation of the Controlled Substances Act of 1970.) (His strategy is ironic, because one thing both the proponents and opponents of P-A-D agree on is that better palliative care is needed for those at the end of life).
    2005—Gonzales v. Oregon appealed from the 9th Court of Appeals (May 26, 2004) to the Supreme Court. The question presented is whether the Attorney General has permissibly construed the Controlled Substances Act to prohibit the distribution of federally controlled substances for the purpose of facilitating an individual’s death, regardless of a state law authorizing such distribution. Oral arguments began on October 5th, 2005.
    2005—California’s AB 654. In light of Gonzales v. Oregon, the issue in California seems moot until the Supreme Court has ruled.
  • 3. Arguments AGAINST Physician-Aid-in-Dying:
    1. Religious. The Roman Catholic hierarchy, conservative evangelical protestant Christians, and orthodox Jews are all opposed to Physician-Assisted Suicide, because of the belief that life is a sacred trust and is infinitely valuable, no matter how diminished its quality; and that ending one’s life prematurely is an offence against God. (What little I know about Islam suggests that most Muslim scholars share this view).
    2, The CMA is opposed to Physician Aid-in-Dying (as it is opposed to any involvement of physicians in carrying out the death penalty) because of the conviction that those in medicine are healers with the obligation to preserve life, and see any involvement in efforts to end people’s lives as contrary to the physician’s calling.
    3, Many Palliative Care and Hospice Providers are opposed to Physician Aid-in-Dying for two reasons: they hold that there is no such thing as unrelievable pain; and they believe that with appropriate end-of-life care the dying process can be invested with sufficient meaning to outweigh any wish to hasten death.
    4. The Lobby for the Disabled is concerned about “the slippery slope”: Hitler’s extermination policies began with the elderly demented and the mentally and physically impaired, and then were extended to Jews, homosexuals, and Gypsies. The Holocaust is a reminder of how easy it is to kill those whom society deems “unwanted” or “undesirable” once the prohibitions and restrictions on ending human life are lifted. Helping the terminally ill to die, or allowing “quality of life considerations” to be factored into the decision-making process, they argue, is the first step down a slippery slope that could place the lives of all with impairments or disabilities in jeopardy.
  • 4. Arguments IN FAVOR of Physician Aid-in-Dying:
    1. Religious. Some Roman Catholic theologians, most mainline Protestant church leaders, and some Reformed Jews support Physician Aid-in Dying. They believe that the quality of life (as defined by oneself, not by others) is as important a decision-making criterion as the sanctity of life, and that there may be times when death is preferable to a life of profoundly diminished quality.
    2. Many oncologists and nurses, as individual professionals not associated with organized medical groups such as the CMA and the AMA, who have actual experience with terminal illness, support Physician Aid-in-Dying. So does the American Medical Student Association, “as a last resort option”, providing criteria similar to those required by Oregon’s Death With Dignity Act are met.
    3. Many Patients (more than 60% of Oregonians who voted in favor of the Death With Dignity Act) claim the right to be self-determining (based on the ethical principle of respect for autonomy), not only in matters relating to their health and well-being but also, when faced with an incurable illness, in determining how and when to die
    4. Patients’ Advocacy Groups such as “Death With Dignity”, “Compassion in Dying”, and the “Hemlock Society” are actively engaged in making this ethical principle of respect for autonomy the basis for proposed legislation legalizing Physician Aid-in-Dying in as many states as possible.
  • 5. The Arguments Briefly Examined Critically:
    1. The religious debate between proponents of the absolute sanctity of life and those who give equal weight to the quality of life. There are strong arguments on both sides, and neither side can finally refute the other’s claims. But a few observations may be in order. While the sanctity of life may be upheld as an absolute value in theory, in practice it is anything but absolute. The theological argument for a “just war” recognizes that there may be times when killing in a just conflict is morally appropriate. Killing in self-defense is also generally recognized as morally permissible in certain circumstances. The pro-life lobby, notoriously and paradoxically, is generally in favor of capital punishment. And within the Jewish and Christian traditions, at least, martyrs are venerated. Martyrs are those who have chosen to die rather than to deny their religious beliefs or disavow their religious duties. Thus, in practice, the value of life is relative rather than absolute.
    The Roman Catholic prohibition against suicide goes back to Aristotle, who held that it is an offence “against nature, and against the self”. In the 12th century, Thomas Aquinas added that taking one’s own life is an offence “against God”. But in the Bible, there are only four references to suicide. Of the three in the Hebrew Scriptures, one is the death of Saul, who “said to his armor-bearer, ‘Draw your sword and run me through, so that these uncircumcised brutes may not come and taunt me and make sport of me.’ But the armor-bearer refused, he dared not; whereupon Saul took his own sword and fell upon it.” (1 Samuel 31:4-5) One could say that Saul chose death rather than dishonor for his people (for to dishonor a King was to shame his people) and that, therefore, his death comes close to martyrdom. The other two (2 Samuel 17:23 and 1 Kings 16:18) recount the suicides of traitors who died by their own hand rather than fall into the hands of those they had betrayed. And in the Christian New Testament the single case is that of Judas (Matthew 27:5). The treachery of these last three, rather than their suicides, is condemned.
    So whereas conservative Jewish and Christian scholars are opposed to Physician Aid-in-Dying and judgmental of those who take their own lives, moderates take a rather more compassionate view, especially of those who, terminally ill and in terrible pain, choose to end their lives. Religion doesn’t settle this issue for us. Unless we have unshakeable religious convictions of our own, it leaves us with the task of making up our own minds, one way or the other.
  • 2. The tension between the medical mandate not to harm and that of alleviating suffering. This is really a tension between two ethical principles: beneficence, which requires that medical professionals benefit their patients (the alleviation of suffering could be construed as an expression of beneficence); and nonmaleficence, which is derived from the ancient maxim, “primum non nocere”—“first of all (or above all else) do no harm.” On the basis of this principle, it could be argued that helping a patient to die, even in the narrow circumstances we are considering, is the ultimate form of harm. We shall return to the tension between these principles in Section 7, when we look at an ethical framework for making up one’s own mind.
  • 3. The argument that all pain is manageable, and that even the process of undignified dying can be invested with meaning. Here we have to applaud the tremendous strides made in pain management and palliative medicine in recent years. It is true, thankfully, that the pain associated with a terminal illness can now, for the most part, be mitigated with enlightened management. But this is not invariably true. There are occasional exceptions. Let me briefly mention one, the case of someone I shall call “Debra.” Debra had lived, fully and meaningfully, with chronic myelogenous leukemia for more than fifteen years. Then, unfortunately, her remission ended . She had developed cellulitis secondary to the chemotherapy that earlier had helped her. Gradually, circulation to her extremities decreased, and her fingers and toes began turning blue, then black, becoming gangrenous and causing exquisite pain. She was referred to Stanford’s pain clinic, where specialists in this area tried everything they knew to give her relief, including nerve blocks. Finally, all they could do was begin amputating her digits, one by one. This, in turn, exacerbated her pain because the wounds left by the amputations wouldn’t heal. She was in constant, unrelieved agony, when her oncologist (who was treating her in her own home), prescribed sufficient sleeping pills for her to end her own life, giving her the tongue-in-cheek warning, “If you take more than two of these at a time, that could kill you. Debra had the prescription filled, and kept the bottle of sleeping pills on the night stand next to her bed. Her husband was willing to help her take them when she could no longer bear her pain. Fortunately, that wasn’t necessary. Debra died quietly of her leukemia, still in pain, without taking the overdose.
    Not only is it not possible to relieve all pain, but there is a crucial difference between pain and suffering. Pain is a physical symptom, suffering is an existential condition, with physical, emotional, psychological, and spiritual components. Caregivers, including those in the Hospice movement, can attempt to alleviate pain and invest their patients’ suffering with meaning. Even when they succeed in alleviating pain, this does not mean that they will necessarily succeed in investing suffering with meaning. There are some terminally ill patients who feel that they have extracted every last ounce of meaning from their suffering, and that the point has long gone when suffering could be construed as meaningful. Now it is not only meaningless, but destructive of everything they have valued in their lives. It is this category of patients whom those in favor of Physician Aid-in-Dying want desperately to help.
  • 4. The slippery slope argument. This argument, in simplified form, is that if society sanctions A, there will be inevitable slippage and before we know it, we will be condoning B, C, D … and so on. The Nazi horrors are invariably held up as a warning of how easily this can (and will) happen. So, the argument runs, if we start by allowing aid-in-dying a la Oregon, we will end up with active euthanasia, as in the Netherlands.
    The fallacy of the slippery slope argument is that slippage is automatic. What some construe as a downhill slope could as well be regarded as an uphill struggle (as our brief review of the history of PAD in this country indicates). And even if there is a downhill slope, moving from A to B to C to D can be prevented by means of regulation and legislation. The best example of this is the record of Oregonians since 1997. The record speaks for itself. There has not been any slippage. Oregon’s Death With Dignity Act is an admirable example of a contentious issue being so tightly regulated that there have been no abuses whatever. To Oregon’s record, we now turn.
  • 6. Oregon’s Death With Dignity Act: Facts and Commentary. I want now to quote directly from the Seventh Annual Report on Oregon’s Death With Dignity Act (Oregon’s legislature required annual reporting when the Act became law).
    TABLE 1
    1998199920002001200220032004
    Number of
    Prescriptions Written 24 33 39 44 58 68 60
    Number of Physicians
    Writing Prescriptions ---------No Figures Available--------- 40
    Number of Deaths
    from Ingesting Medication 16 27 27 21 38 42 37
    Number Not Ingesting
    Medication 8 6 12 23 20 26 23
    Ratio of PAD Deaths to
    every 10,000 Total Deaths 5.5 9.2 9.1 7.012.213.6 12
  • Since the Death With Dignity Act was implemented:
    49% of PAS patients used secobarbital
    50% used pentobarbital
    2% used either secobarbital/amobarbital or secobarbital/morphine
  • Several comments are in order:
    1) According to the Report, “The most frequently reported concerns [of patients requesting medication to end their lives] were a decreased ability to participate in activities that make life enjoyable (92%), losing autonomy (87%), and loss of dignity (78%).” With respect to concerns about losing autonomy, the fact that a significant number of patients who requested medication to end their lives did not end up ingesting it suggests that, as in the case of “Debra” mentioned earlier, having the medication available gave them a sense of being in control rather than at the mercy of their disease.
  • 2) 79% of patients requesting PAD suffered from malignant neoplasms—lung and bronchus (19%). breast (9%), pancreas (9%), colon (6%), and other (36%).
  • 8% had ALS, 5% chronic lower respiratory disease, and 2% HIV/AIDS.
  • 3) The prescribing physicians of patients who used PAD during 2004 (no figures are available before 2004) had been in practice for a median of 22 years. 70% wrote just a single prescription. Their specialties were family medicine (57%), oncology (22%), internal medicine (8%), and other (14%).
  • 4) The Report concludes with the following observation: “While it may be common for patients with a terminal illness to consider PAS , a request for PAS can be an opportunity for a medical provider to explore with patients their fears and wishes around end-of-life-care, and to make patients aware of other options. Often, once the patient’s concerns have been addressed by the provider, he or she may choose not to pursue PAS. The availability of PAS as an option in Oregon also may have spurred Oregon doctors to address other end-of-life care options more effectively. In one study, Oregon physicians reported that, since the passage of the Death With Dignity Act in 1994, they had made efforts to improve their knowledge of the use of pain medications in the terminally ill, to improve their recognition of psychiatric disorders such as depression, and to refer patients more frequently to hospice.”
  • 7. An Ethical Framework for Making Up One’s OWN Mind:
    In conclusion, I want to suggest that in making up one’s own mind ethically in a way that will be publicly defensible, at least four elements have to be kept in view.
    1) One has to have as much factual information as possible. This information should include the patient’s history, diagnosis, prognosis, and mental status; information about the patient’s beliefs and values, as well as socio-economic condition; data from the literature pertinent to the patient’s medical condition; information, if possible, about how family members feel about a patient’s request for aid-in-dying; epidemiological data; and information about what sort of insurance the patient has, what treatment the patient has been able to receive, and where.
    2) One has to identify the patient’s (and one’s own) beliefs pertinent to this issue and the values to which they give rise: these beliefs, and concomitant values, can be religious, ethnic, cultural, institutional, as well as professional. Values are frequently in conflict, and these conflicts can not necessarily be resolved by reasoned discussion. Remember that people not only live by their beliefs, but are often willing to die for them (Jehovah’s Witnesses and their refusal of blood products. or terminally ill patients who believe that their life is of insufficient quality and prefer death to having to continue to live a diminished life). One has to go as far as one can in terms of respecting the values held by others, without doing violence to one’s own.
    3) The rational principles of biomedical ethics: beneficence, nonmaleficence, autonomy, and justice (distributively understood). These principles (which have evolved historically) are always in tension. We have noted the tension between beneficence (which could be construed to require the alleviation of suffering) and nonmaleficence (when interpreted to mean that no greater harm can be done to a patient that to enable him/her to die). However, to prolong someone’s suffering, especially against his/her will, could also be seen as harming that person. Which interpretation an individual oncologist decides to adopt will depend on both the circumstances of the situation and the oncologist’s own values. Respect for autonomy is the principle to which those choosing PAD appeal, and the physician’s willingness to honor this principle can be in tension with the principle of nonmaleficence (when helping a patient die is believed to be the ultimate form of harm). And the principle of distributive justice may very well be in tension with respect for autonomy. Consider this important statement from the American Medical Student Association’s (AMSA’s) Principles Regarding Physician-Assisted Suicide: “Equal access to health care is one relevant issue in the aid-in-dying debate. These guidelines are an effort to guard against potential abuse because of inequities with regard to health care access. Therefore, it is important for AMSA simultaneously to advance its efforts in addressing both issues of health care access as well as aid-in-dying.” The point AMSA is making is that where terminally ill patients do not have access to the best possible palliative and end-of-life care, they may well choose death rather than life. Yet this choice will then have been coerced by circumstances, rather than being an authentic expression of the patient’s deepest values.
    None of these principles automatically trumps the others. Weighing which is be given priority has to be done in light of 1) and 2) above, and 4) below.
    Factors extrinsic or external to the clinical situation, which nevertheless impinge on it. Nationally, the political pendulum appears to have swung away from the liberal to the conservative side of its arc. This may very well change the nature of the Supreme Court in the near future. The Supreme Court ruling on Gonzales v. Oregon will have major repercussions. There may well be new laws and regulations with respect to physician aid-in-dying and the prescribing of palliative medications that could have the secondary effect of hastening death. The next speaker, I am sure, will touch on the likely shape of legislation in this area. My point, here, though, is that no practitioner (who wishes to keep his/her license to practice medicine) can afford to ignore or be oblivious to these external factors.
    To sum up, the work of ethical decision-making requires information, insight into values, the weighing of the traditional medical principles, and attention to extrinsic factors such as the law. There is no substitute to going through this process. And as one goes through it, it has to be with enough humility to recognize that others, having gone through a similar process, may legitimately come out drawing different conclusions and making different decisions to one own.
  • THREE CASE STUDIESFOR SMALL GROUP DISCUSSIONDURING THE Q and A PERIOD1.  “Debra” had lived, fully and meaningfully, with chronic myelogenous leukemia for more than fifteen years. Then, unfortunately, her remission ended . She had developed cellulitis secondary to the chemotherapy that earlier had helped her. Gradually, circulation to her extremities decreased, and her fingers and toes began turning blue, then black, becoming gangrenous and causing exquisite pain. She was referred to Stanford’s pain clinic, where specialists in this area tried everything they knew to give her relief, including nerve blocks. Finally, all they could do was begin amputating her digits, one by one. This, in turn, exacerbated her pain because the wounds left by the amputations wouldn’t heal, and she still had “phantom pain” where her fingers and toes had been. She was in constant, unrelieved agony, when her oncologist (who was treating her in her own home), prescribed sufficient sleeping pills for her to end her own life, giving her the tongue-in-cheek warning, “If you take more than two of these at a time, that could kill you. Debra had the prescription filled, and kept the bottle of sleeping pills on the night stand next to her bed. Her husband was willing to help her take them when she could no longer bear her pain. Fortunately, that wasn’t necessary. Debra died quietly of her leukemia, still in pain, without taking the overdose.
    If Debra were your patient, would or would you not do for her what her oncologist did? Use the ethical framework to describe the reasons for your decision. 
  • 1.  “Debra” had lived, fully and meaningfully, with chronic myelogenous leukemia for more than fifteen years. Then, unfortunately, her remission ended . She had developed cellulitis secondary to the chemotherapy that earlier had helped her. Gradually, circulation to her extremities decreased, and her fingers and toes began turning blue, then black, becoming gangrenous and causing exquisite pain. She was referred to Stanford’s pain clinic, where specialists in this area tried everything they knew to give her relief, including nerve blocks. Finally, all they could do was begin amputating her digits, one by one. This, in turn, exacerbated her pain because the wounds left by the amputations wouldn’t heal. She was in constant, unrelieved agony, when her oncologist (who was treating her in her own home), prescribed sufficient sleeping pills for her to end her own life, giving her the tongue-in-cheek warning, “If you take more than two of these at a time, that could kill you. Debra had the prescription filled, and kept the bottle of sleeping pills on the night stand next to her bed. Her husband was willing to help her take them when she could no longer bear her pain. Fortunately, that wasn’t necessary. Debra died quietly of her leukemia, still in pain, without taking the overdose.
    If Debra were your patient, would or would you not do for her what her oncologist did? Use the ethical framework to describe the reasons for your decision. 
  • 2.  A Vietnam veteran, who lost both his legs in that war, and who is not a churchgoer, is your patient.  He now has end-stage laryngeal-esophageal carcinoma.  Until recently, he was able to take small amounts of liquid nourishment by mouth.  Now it is apparent that, if he is to survive, he needs artificial nutrition and hydration.  He is opposed to this, saying that he has nothing left to live for.  His wife, a devout Roman Catholic, makes an appointment to see you, says that she believes her husband is depressed, has been stock-piling the opiates you have been prescribing for his pain, and intends to end his life with an overdose.  She implores you to intervene, because she considers suicide a mortal sin and cannot bear to think of life without him. What, if anything, do you do?Use the ethical framework to explain your answer. In arriving at your decision, what weight, if any, do you give to the concerns of the lobbyists for the disabled? 
  • 2.  A Vietnam veteran, who lost both his legs in that war, and who is not a churchgoer, is your patient.  He now has end-stage laryngeal-esophageal carcinoma.  Until recently, he was able to take small amounts of liquid nourishment by mouth.  Now it is apparent that, if he is to survive, he needs artificial nutrition and hydration.  He is opposed to this, saying that he has nothing left to live for.  His wife, a devout Roman Catholic, makes an appointment to see you, says that she believes her husband is depressed, has been stock-piling the opiates you have been prescribing for his pain, and intends to end his life with an overdose.  She implores you to intervene, because she considers suicide a mortal sin and cannot bear to think of life without him. What, if anything, do you do?Use the ethical framework to explain your answer. In arriving at your decision, what weight, if any, do you give to the concerns of the lobbyists for the disabled? 
  • 3.  A 51-year old senior United Airlines flight attendant (who had flown international routes for most of her career) has been admitted to the hospital with end-stage ovarian cancer.  She is single, and has been an extraordinarily beautiful woman, taking much pride in her appearance.  Now she cannot bear to see her beauty being ravaged by her disease, nor does she want her colleagues, many of whom are flying in to visit her literally from all over the world, to see her in her present condition.  You are her oncologist.  She asks you to provide her with conscious sedation, that is, to keep her below the level of consciousness while she gradually dies without natural or artificial hydration or nutrition. Is your patient asking for physician aid-in-dying, or not?  Why do you think this? How would you use the ethical framework to respond to her request?
  • 3.  A 51-year old senior United Airlines flight attendant (who had flown international routes for most of her career) has been admitted to the hospital with end-stage ovarian cancer.  She is single, and has been an extraordinarily beautiful woman, taking much pride in her appearance.  Now she cannot bear to see her beauty being ravaged by her disease, nor does she want her colleagues, many of whom are flying in to visit her literally from all over the world, to see her in her present condition.  You are her oncologist.  She asks you to provide her with conscious sedation, that is, to keep her below the level of consciousness while she gradually dies without natural or artificial hydration or nutrition. Is your patient asking for physician aid-in-dying, or not?  Why do you think this? How would you use the ethical framework to respond to her request?
  • Ethical Issues in Medical Oncology: Physician Aid-in-Dying

    1. 1. Ethical Issues in MedicalEthical Issues in Medical Oncology: Physician Aid-in-DyingOncology: Physician Aid-in-Dying ErnlErnléé W.D. Young Ph.D., Professor ofW.D. Young Ph.D., Professor of Medicine Emeritus (Biomedical Ethics)Medicine Emeritus (Biomedical Ethics) Stanford University School of MedicineStanford University School of Medicine
    2. 2. OutlineOutline 1.1. Define Physician Aid-in-Dying (PAD)Define Physician Aid-in-Dying (PAD) 2.2. History of PADHistory of PAD 3.3. ArgumentsArguments AgainstAgainst PADPAD 4.4. ArgumentsArguments in Favorin Favor of PADof PAD 5.5. Weighing the ArgumentsWeighing the Arguments 6.6. Oregon’sOregon’s Death With DignityDeath With Dignity ActAct 7.7. Making up One’sMaking up One’s OwnOwn Mind:Mind: An Ethical Framework and Three CaseAn Ethical Framework and Three Case Scenarios for Small Group DiscussionScenarios for Small Group Discussion
    3. 3. What is Physician Aid-in-Dying?What is Physician Aid-in-Dying? Modeled on Oregon’sModeled on Oregon’s Death WithDeath With Dignity ActDignity Act As Set Out in California’s AB 654As Set Out in California’s AB 654 A Process to Request Life-endingA Process to Request Life-ending MedicationMedication
    4. 4. Oregon’s Death With Dignity ActOregon’s Death With Dignity Act An Adult (18 Years of Age or Older)An Adult (18 Years of Age or Older) A Resident of OregonA Resident of Oregon Capable (Defined as Able to MakeCapable (Defined as Able to Make and Communicate Health Careand Communicate Health Care Decisions)Decisions) Diagnosed With a Terminal IllnessDiagnosed With a Terminal Illness That Will Lead to Death Within SixThat Will Lead to Death Within Six MonthsMonths
    5. 5. Requirements for Lethal MedicationRequirements for Lethal Medication Two Oral RequestsTwo Oral Requests A Written RequestA Written Request A Confirmed Diagnosis & PrognosisA Confirmed Diagnosis & Prognosis Patient Must be CapablePatient Must be Capable If Judgment is Impaired, the PatientIf Judgment is Impaired, the Patient Must be ReferredMust be Referred Must be Informed of AlternativesMust be Informed of Alternatives Notification of Next of KinNotification of Next of Kin
    6. 6. A Brief ChronologyA Brief Chronology 1991—Washington’s Proposition 119, Narrowly1991—Washington’s Proposition 119, Narrowly DefeatedDefeated 1992—California’s Proposition 162, Narrowly Defeated1992—California’s Proposition 162, Narrowly Defeated 1994—Oregon’s Measure 16, Passed by 51/491994—Oregon’s Measure 16, Passed by 51/49 1996—91996—9thth and 2and 2ndnd Circuits Courts of Appeal rule StateCircuits Courts of Appeal rule State Prohibitions on P-A-D UnconstitutionalProhibitions on P-A-D Unconstitutional 1997—The Supreme Court Reverses, But Leaves the1997—The Supreme Court Reverses, But Leaves the Door OpenDoor Open 1997—Oregon’s Measure 16 Reaffirmed by 60/401997—Oregon’s Measure 16 Reaffirmed by 60/40 1998—Measure 16 Becomes Law in Oregon1998—Measure 16 Becomes Law in Oregon 2004—Ashcroft Moves to Criminalize the Prescription of2004—Ashcroft Moves to Criminalize the Prescription of Medicine that “Will Result in Patients’ Deaths.”Medicine that “Will Result in Patients’ Deaths.” 2005—Gonzales v. Oregon appealed to Supreme Court2005—Gonzales v. Oregon appealed to Supreme Court 2005—California’s AB 654 now Moot2005—California’s AB 654 now Moot
    7. 7. Arguments AGAINST PADArguments AGAINST PAD ReligiousReligious The CMAThe CMA Many Palliative Care & Hospice ProvidersMany Palliative Care & Hospice Providers The Lobby for the DisabledThe Lobby for the Disabled
    8. 8. Arguments IN FAVOR of PADArguments IN FAVOR of PAD ReligiousReligious Many Oncologists and NursesMany Oncologists and Nurses Many PatientsMany Patients Patients’ Advocacy GroupsPatients’ Advocacy Groups
    9. 9. Weighing the ArgumentsWeighing the Arguments Absolute Sanctity vs. Quality of LifeAbsolute Sanctity vs. Quality of Life The Roman Catholic ProhibitionThe Roman Catholic Prohibition The Biblical References to SuicideThe Biblical References to Suicide The View of ModeratesThe View of Moderates 1. The Religious Debate1. The Religious Debate
    10. 10. Weighing the ArgumentsWeighing the Arguments Beneficence andBeneficence and NonmaleficenceNonmaleficence 2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:
    11. 11. Weighing the ArgumentsWeighing the Arguments Pain is ManageablePain is Manageable Not Possible to Relieve All PainNot Possible to Relieve All Pain Difference Between Pain and SufferingDifference Between Pain and Suffering 3. Dying Invested with Meaning3. Dying Invested with Meaning
    12. 12. Weighing the ArgumentsWeighing the Arguments The Simplified Form of this ArgumentThe Simplified Form of this Argument The Fallacy, Slippage is Not AutomaticThe Fallacy, Slippage is Not Automatic Oregon’s Record Speaks for ItselfOregon’s Record Speaks for Itself There has not been any slippageThere has not been any slippage 4. The Slippery Slope Argument4. The Slippery Slope Argument
    13. 13. 19981998 19991999 20002000 20012001 20022002 20032003 20042004 Number ofNumber of Prescriptions WrittenPrescriptions Written 2424 3333 3939 4444 5858 6868 6060 Number of PhysiciansNumber of Physicians Writing PrescriptionsWriting Prescriptions 4040 Number of Deaths fromNumber of Deaths from Ingesting MedicationsIngesting Medications 1616 2727 2727 2121 3838 4242 3737 Number Not IngestingNumber Not Ingesting MedicationMedication 88 66 1212 2323 2020 2626 2323 Ratio of PAS Deaths toRatio of PAS Deaths to Every 10,000 Total DeathsEvery 10,000 Total Deaths 5.55.5 9.29.2 9.19.1 7.07.0 12.212.2 13.613.6 1212 ---------No Figures Available-----------------No Figures Available-------- Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary Figures from the Seventh Annual Report on Oregon’sFigures from the Seventh Annual Report on Oregon’s DeathDeath With Dignity ActWith Dignity Act
    14. 14. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary 49% of PAD patients used secobarbital49% of PAD patients used secobarbital 50% used pentobarbital50% used pentobarbital 2% used either2% used either secobarbital/amobarbital orsecobarbital/amobarbital or secobarbital/morphinesecobarbital/morphine Since theSince the Death With Dignity ActDeath With Dignity Act waswas Implemented:Implemented:
    15. 15. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary Decreased Ability to Participate inDecreased Ability to Participate in Activities that Make Life EnjoyableActivities that Make Life Enjoyable (92%)(92%) Losing Autonomy (87%)Losing Autonomy (87%) Loss of Dignity (78%)Loss of Dignity (78%) Most Frequently Reported Concerns:Most Frequently Reported Concerns:
    16. 16. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary Malignant Neoplasms (79%)Malignant Neoplasms (79%) Lung and Bronchus (19%)Lung and Bronchus (19%) Breast (9%)Breast (9%) Pancreas (6%)Pancreas (6%) Colon (6%)Colon (6%) Other (36%)Other (36%) Patients Requesting PAD Suffered from:Patients Requesting PAD Suffered from:
    17. 17. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary ALS (8%)ALS (8%) Chronic Lower Respiratory (5%)Chronic Lower Respiratory (5%) HIV/AIDS (2%)HIV/AIDS (2%) Patients Requesting PAD Suffered from:Patients Requesting PAD Suffered from:
    18. 18. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary Of Physicians Who Complied withOf Physicians Who Complied with Patient Requests for PAD:Patient Requests for PAD: 57% Practiced Family Medicine57% Practiced Family Medicine 22% Were Oncologists22% Were Oncologists 8% Were Internists8% Were Internists 70% Wrote Only a Single70% Wrote Only a Single PrescriptionPrescription
    19. 19. Oregon’sOregon’s Death With Dignity ActDeath With Dignity Act:: Facts and CommentaryFacts and Commentary A Request for PAS Can:A Request for PAS Can: Be an Opportunity to Explore FearsBe an Opportunity to Explore Fears and Wishes Around End-of-Life Careand Wishes Around End-of-Life Care Make Patients Aware of Their OptionsMake Patients Aware of Their Options
    20. 20. An Ethical FrameworkAn Ethical Framework Elements in Making Up One’s Own Mind:Elements in Making Up One’s Own Mind: Acquire As Much Factual Information asAcquire As Much Factual Information as PossiblePossible Identify Beliefs and ValuesIdentify Beliefs and Values Apply the Principles of Biomedical EthicsApply the Principles of Biomedical Ethics Factor in Data Extrinsic to the Clinical Situation,Factor in Data Extrinsic to the Clinical Situation, Such as the LawSuch as the Law
    21. 21. Scenario 1Scenario 1 ““Debra” had lived, fully and meaningfully, with chronic myelogenousDebra” had lived, fully and meaningfully, with chronic myelogenous leukemia for more than fifteen years. Then, unfortunately, herleukemia for more than fifteen years. Then, unfortunately, her remission ended. She had developed cellulitis secondary to theremission ended. She had developed cellulitis secondary to the chemotherapy that earlier had helped her. Gradually, circulation to herchemotherapy that earlier had helped her. Gradually, circulation to her extremities decreased, and her fingers and toes began turning blue,extremities decreased, and her fingers and toes began turning blue, then black, becoming gangrenous and causing exquisite pain. Shethen black, becoming gangrenous and causing exquisite pain. She was referred to Stanford’s pain clinic, where specialists in this fieldwas referred to Stanford’s pain clinic, where specialists in this field tried everything they knew to give her relief, including nerve blocks.tried everything they knew to give her relief, including nerve blocks. Finally, all they could do was begin amputating her digits, one by one.Finally, all they could do was begin amputating her digits, one by one. This, in turn, exacerbated her pain because the wounds left by theThis, in turn, exacerbated her pain because the wounds left by the amputations wouldn’t heal, and she still had “phantom pain”. She wasamputations wouldn’t heal, and she still had “phantom pain”. She was in constant, unrelieved agony, when her oncologist (who was treatingin constant, unrelieved agony, when her oncologist (who was treating her in her own home), prescribed sufficient sleeping pills for her to endher in her own home), prescribed sufficient sleeping pills for her to end her own life, giving her the tongue-in-cheek warning, “If you take moreher own life, giving her the tongue-in-cheek warning, “If you take more than two of these at a time, that could kill you.”than two of these at a time, that could kill you.” Page 1Page 1
    22. 22. Scenario 1Scenario 1 Debra had the prescription filled, and kept the bottle of sleeping pillsDebra had the prescription filled, and kept the bottle of sleeping pills on the night stand next to her bed. Her husband was willing to helpon the night stand next to her bed. Her husband was willing to help her take them when she could no longer bear her pain. Fortunately,her take them when she could no longer bear her pain. Fortunately, that wasn’t necessary. Debra died quietly of her leukemia, still in pain,that wasn’t necessary. Debra died quietly of her leukemia, still in pain, without taking the overdose.without taking the overdose. If Debra had been your patient, would or would you not have done forIf Debra had been your patient, would or would you not have done for her what her oncologist did?her what her oncologist did? Use the ethical framework to describe the reasons for your decision.Use the ethical framework to describe the reasons for your decision. Page 2Page 2
    23. 23. Scenario 2Scenario 2 A Vietnam veteran, who lost both his legs in that war, and who is not aA Vietnam veteran, who lost both his legs in that war, and who is not a churchgoer, is your patient. He now has end-stage laryngeal-churchgoer, is your patient. He now has end-stage laryngeal- esophageal carcinoma. Until recently, he was able to take smallesophageal carcinoma. Until recently, he was able to take small amounts of liquid nourishment by mouth. Now it is apparent that, if heamounts of liquid nourishment by mouth. Now it is apparent that, if he is to survive, he needs artificial nutrition and hydration. He is opposedis to survive, he needs artificial nutrition and hydration. He is opposed to this, saying that he has nothing left to live for.to this, saying that he has nothing left to live for. Page 1Page 1
    24. 24. Scenario 2Scenario 2 His wife, a devout Roman Catholic, makes an appointment to see you,His wife, a devout Roman Catholic, makes an appointment to see you, says that she believes her husband is depressed, has been stock-says that she believes her husband is depressed, has been stock- piling the opiates you have been prescribing for his pain, and intendspiling the opiates you have been prescribing for his pain, and intends to end his life with an overdose. She implores you to intervene,to end his life with an overdose. She implores you to intervene, because she considers suicide a mortal sin and cannot bear to think ofbecause she considers suicide a mortal sin and cannot bear to think of life without him.life without him. What, if anything, do you do?What, if anything, do you do? Use the ethical framework to explain your answer.Use the ethical framework to explain your answer. In arriving at your decision, what weight, if any, do you give to theIn arriving at your decision, what weight, if any, do you give to the concerns of the lobbyists for the disabled?concerns of the lobbyists for the disabled? Page 2Page 2
    25. 25. Scenario 3Scenario 3 A 51-year old senior United Airlines flight attendant (who had flownA 51-year old senior United Airlines flight attendant (who had flown international routes for most of her career) has been admitted to theinternational routes for most of her career) has been admitted to the hospital with end-stage ovarian cancer. She is single, and had beenhospital with end-stage ovarian cancer. She is single, and had been an extraordinarily beautiful woman, taking much pride in heran extraordinarily beautiful woman, taking much pride in her appearance. Now she cannot bear to see her beauty being ravagedappearance. Now she cannot bear to see her beauty being ravaged by her disease, nor does she want her colleagues, many of whom areby her disease, nor does she want her colleagues, many of whom are flying in to visit her literally from all over the world, to see her in herflying in to visit her literally from all over the world, to see her in her present condition.present condition. Page 1Page 1
    26. 26. Scenario 3Scenario 3 You are her oncologist. She asks you to provide her with consciousYou are her oncologist. She asks you to provide her with conscious sedation, that is, to keep her below the level of consciousness whilesedation, that is, to keep her below the level of consciousness while she gradually dies without natural or artificial hydration or nutrition.she gradually dies without natural or artificial hydration or nutrition. Is your patient asking for physician aid-in-dying, or not? Why do youIs your patient asking for physician aid-in-dying, or not? Why do you think this?think this? How would you use the ethical framework to respond to her request?How would you use the ethical framework to respond to her request? Page 2Page 2
    27. 27. Apply the Ethical FrameworkApply the Ethical Framework Acquire As Much Factual Information asAcquire As Much Factual Information as PossiblePossible Identify Beliefs and ValuesIdentify Beliefs and Values Apply the Principles of Biomedical EthicsApply the Principles of Biomedical Ethics Factor in Data Extrinsic to the Clinical Situation,Factor in Data Extrinsic to the Clinical Situation, Such as the LawSuch as the Law
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