“Physician-Assisted Dying: Is a Patient’s Despair Reversible?” by Arthur Caplan, PhD. And Maurie Markman, MD

A while back, I received a phone call asking me to talk to a man in another state who was desperately seeking physician-assisted suicide. He was in the later stages of a degenerative disease and wanted to die before his condition “got too bad”.

I talked to this man I will call “John” for quite a while about his life, his frustrations, his strengths, some resources, etc. He said he had told his caregivers at the nursing home that he would like to talk to someone about his concerns months ago but nothing happened. With his permission, I spoke to his caregivers and I asked John to keep in touch.

About a month later, John contacted me and said that he had changed his mind about assisted suicide and was enjoying being with friends and going out on trips with other residents.

He said the biggest help was talking with someone like me who listened and who cared.  Best of all, he said “I do deserve a better life!”

I thought about John when I read an April 06, 2017 commentary from Medscape, a password protected news site for medical professionals, titled “Physician-Assisted Dying: Is a Patient’s Despair Reversible?” 

The commentary was a discussion between Arthur Caplan, PhD, a prominent ethicist  who was against legalizing assisted suicide until the Brittany Maynard case, and Maurie Markman, MD, an oncologist and professor who also supports assisted suicide, that I found disturbing.

For example, Dr. Markman says that:

 “My concern is that the reason someone may ask for death, which is their right, is because of despair. Despair may be potentially temporary or it may be permanent, but death itself is permanent. My concern would be that some part of an individual patient’s despair may be reversible; I would want to be certain that it is not reversible before deciding that this (physician-assisted suicide) makes sense for that person, from my perspective.”
(Emphasis added)

But amazingly, neither Dr. Markman or Dr. Caplan even mentions or recommends  mental health evaluations for people considering assisted suicide-something which no assisted suicide law now requires because such suicides are considered “rational”.

Instead, there is this exchange:

Dr Caplan: I remember when Jack Kevorkian was bringing people to Michigan and helping them die in the back of Volkswagen vans and so on. One problem I had was that he did not know these people.

Dr Markman: That’s right.

Dr Caplan: They would show up, and 24 hours later, they would be gone to the hereafter; some of them were terminally ill, and some were not, as a matter of fact. Given the constraints that physicians face in terms of time and other activities they have to engage in—paperwork and so on—can they get to know patients well enough to have reliable discussions about the authenticity of their wishes to die?

Dr Markman: That is a concern. Physicians don’t have enough time to do a lot of things. The kind of conversation we are talking about would involve a lot of time and effort. I would suggest that physicians would want to be able to spend that time with their patients, but it does not mean they have that time. Quite frankly, it may be relatively immediate time. A patient comes in at a particular point and says, I’m thinking of doing this and I’m thinking of doing it now, and the doctor has a full schedule. The physician would want to take that time, would want to bring in the family, but it is difficult with time constraints. (Emphasis added)

There is another discussion of financial burdens impacting assisted suicide, with Dr. Caplan saying:

Dr. Caplan: Here is a source of growing despair: These treatments (for cancer) are causing me to go broke. I cannot afford a $100,000 biologic or immunotherapy, or I simply do not want to linger on and on while my grandson’s tuition is spent, or whatever. We have come to think about this as the problem of financial toxicity: more tools, but more associated cost. How does physician-assisted dying fit into this emerging area of financial burden?

Dr. Markman: … The potential for bankruptcy is becoming a major issue among patients with cancer. We know that during the Great Depression, people went bankrupt and committed suicide. Why could it not happen now, when we are talking about therapies that cost hundreds of thousands of dollars a year and patients have copays of 20%? Financial toxicity is real.” (Emphasis added)

CONCLUSION

Where is the compassion for these suicidal people grappling with issues that lead them to consider physician-assisted suicide?

This dispassionate discussion of some qualms that these supposed experts seem to have about physician-assisted suicide still leaves assisted suicide laws intact and does nothing to promote non-discriminatory suicide prevention and treatment or even conscience rights for those of us who oppose physician-assisted suicide.

Health Care Bullying Over Conscience Rights

Years ago, some of my fellow nurses were talking about assisted suicide and two of them supported physician-assisted suicide. I asked if they were comfortable with participating in an assisted suicide. Both were shocked and said no.

They believed the myth that doctors just write lethal prescriptions that patients then go home and take privately. It never occurred to them that they could be involved if the assisted suicide occurred in a healthcare institution, home health situation, etc. where they-unlike the doctor-could not just walk away.

These nurses were unaware that there were already nursing journal articles like “Assisted Suicide: What Role for Nurses?”  (2000) that quoted one Oregon hospice administrator:

“Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients…but in reality, nurses are usually the ones in the line of fire.

While Compassion and Choices leaders now talk about “integrating” and “normalizing” assisted suicide in end of life care , this 17 year old article already stated that “Much of nurses’ roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.” (Emphasis added)

Now, two recent articles expose the lengths that assisted suicide activists will go to  legally bully health care professionals to participate in medically assisted suicide.

VERMONT

In an April 5, 2017 article titled “This State is Trying for Force Doctors and Health Care Workers to Give Patients Info on Assisted Suicide”, the Alliance Defending Freedom organization  filed a lawsuit against Vermont’s Act 39, arguing that

“Vermont’s Act 39 makes the State the first and only one to mandate that all licensed healthcare professionals counsel terminal patients about the availability and procedures for physician-assisted suicide, and refer them to willing prescribers to dispense the death-dealing drug. Act 39 coerces professionals to counsel patients about the ‘benefits’ of assisted suicide—benefits that Plaintiffs’ members do not believe exist—and in addition stands in opposition to a federal law protecting healthcare professionals who cannot participate in assisted suicide for conscientious reasons.” (Emphasis added)

CANADA

In a stunning March 28, 2017 Canadian Catholic Register article titled “Doctors being ’bullied’ over assisted suicide, legislators told at Bill 84 hearings” , doctors in Ontario, Canada spoke out about “being bullied, silenced and coerced in a pro-euthanasia environment which is forcing those who object to medically assisted suicide to provide an “effective referral” for patients who wish to die”. (Emphasis added)

Dr. Jane Dobson testified about the pressure she has faced: “If I don’t comply, I face fines and the possible suspension of my license.”

University of Toronto School of Medicine professor Dr. Maria Wolfs added that medical schools are facing pressure to “weed out students who might object to assisted suicide”. (Emphasis added)

Psychiatrist Dr. Janice Halpern testified that the policy is also “at odds with the subtleties of a psychiatric doctor-patient relationship and asked how long can a psychiatrist work with a patient “on finding their will to live again” before referring the patient for assisted suicide.

The Canadian Supreme Court legalized physician-assisted suicide in 2015 and as of the end of 2016, at least 744 people have died from physician assisted suicide with Ontario having the highest number.

One doctor who assisted the suicide of at least 40 patients in 2016 said that those numbers will increase “to the point of the Netherlands and Belgium because their laws are similar to ours, and that would mean about 5 % of all deaths.”

UNEXPECTED CONSEQUENCES

Ironically, there has been an unusual backlash in Canada.

According to a February 2017 article in Canada’s National Post newspaper , an increasing number of doctors performing assisted suicide are now saying “‘Take my name off the list, I can’t do any more”.  As the article states:

“In Ontario, one of the few provinces to track the information, 24 doctors have permanently been removed from a voluntary referral list of physicians willing to help people die. Another 30 have put their names on temporary hold.”

And

“The Canadian Medical Association says reports of doctors backing away from the act are not just anecdotal. “I can’t tell you how many, but I can tell you that it’s enough that it’s been noted at a systemic level,” said Dr. Jeff Blackmer, the CMA’s vice-president of medical professionalism.”

CONCLUSION

Groups like Compassion and Choices depend on assisted suicide being portrayed as a victimless and necessary medical intervention while, at the same time, they oppose conscience rights for ethical doctors and nurses trying to help and protect their patients and their professions.

However, it is hard to escape the reality that legally forced participation in medically assisted suicide damages the health care system, health care providers and even patients.

Why Physician-assisted Suicide Cannot be a Civil Right

Although groups like Compassion and Choices insist that assisted suicide is a civil right despite the 1997 US Supreme Court unanimously finding no constitutional right to assisted suicide,  this is a recipe for disaster.

Civil rights means equality under the law so equality in assisted suicide means that the “right” to assisted suicide logically cannot remain limited to just mentally competent adults with a prognosis of 6 months and able to give themselves lethal overdoses by mouth. What about the non-terminally ill person with paralysis who can’t take the lethal overdose by himself or herself? What about the person with Alzheimer’s who is no longer mentally competent to make the decision for medically assisted suicide? What about the lucid chronically mentally ill person who wants to end years of struggling?

It is inevitable that assisted suicide as a civil right must necessarily expand to anyone using any prescribed method for any situation deemed intolerable.

We have already seen this happen in European countries like Holland and Belgium as well as the current lethal injection assisted suicides in Canada and now even paired with organ donation.

ECONOMICS AND BURDENS

A recent Canadian study predicted that physician-assisted suicide could save Canada up to $139 million dollars each year.

The study’s author states that “Neither patients nor physicians should consider costs when making the very personal decision to request, or provide, this intervention” but the reality is that people, especially older individuals, do worry about being a financial and/or physical burden on their families and almost 50% of assisted suicide victims in the latest 2016 Oregon report cited “burden on family, friends/caregivers” as a concern.

I am not surprised. My own mother often told me that she never wanted to be a burden on her family even before she developed Alzheimer’s and terminal cancer. Mom thought she was just being a loving mother without realizing that such an attitude and statement can have lethal consequences even outside of assisted suicide.

For example, years ago when I worked in oncology, I cared for a delightful elderly woman with cancer whose doctors recommended another chemo treatment. My patient confided that she did want to try it but feared becoming more of a “burden” on her daughter’s family with whom she lived.

I told her that I had just spoken to her daughter the day before and the daughter told me how grateful she was for her mother’s presence and help. For example, the daughter said that since she and her husband both worked, they were relieved to have the mother there for their school-age children when classes ended. The daughter told me how the children loved climbing into bed with grandma and telling her about their day.

My elderly patient was almost reduced to tears but by this revelation but then she laughed and admitted that sometimes she fell asleep when the children were talking to her.

I told my patient that whatever else she needed to consider before agreeing to the chemo, fear about being a “burden” should be eliminated.

CONCLUSION

People with disabilities are especially right to be concerned about the coercion of economics and perceived “burdens” of living when assisted suicide is legalized.

I learned this first hand when my daughter Karen was born with Down Syndrome and a severe heart defect. Even though I insisted that my daughter be treated the same as any other child with this condition, I was shocked by the responses of some fellow health care providers.

One doctor actually said that “People like you shouldn’t be saddled with a child like that”.  I was shocked and challenged him that, since my husband and I were medical professionals and especially able to care for a child with a heart problem and Down Syndrome, exactly who were these “right kind” of parents? Apparently none.

Later on, when Karen was secretly made a Do Not Resuscitate while hospitalized for pneumonia because I was supposedly “too emotionally involved with that retarded baby”,  I was shocked to how easily choice can indeed become an illusion when it comes to people with disabilities.

Unfortunately, it is a very small step from “I wouldn’t want to live (or have a child) like that” to “no one should have to live (or have a child) like that”.

Legalizing the demand for medical professionals to help end the lives of only certain people cannot be a true civil right or ultimately  even limited to “just” the mentally competent terminally ill.