‘Ethically, Is This Right For Doctors To Do?’ Help A Terminal Patient Die?

(Photo illustration by Alex Kingsbury/WBUR)

Ravi Parikh, a fourth-year student at Harvard Medical School, faced conflicting messages.

The American Medical Association, which he belongs to, and the Massachusetts Medical Society oppose Question 2, the measure on next month’s state ballot that would allow terminally ill patients to ask a doctor to prescribe them life-ending drugs.

Harvard Medical School student Ravi Parikh

In contrast, The American Medical Student Association, which he also belongs to, supports it.

Ravi faced conflict within as well. He’d applied to medical school for the usual reason — to heal patients, as spelled out in the Hippocratic oath — not to help them die.

But his medical education introduced him to the complexities of modern American dying.

It stressed patient autonomy as a “central guidepost.” Yet he saw patients losing control as they neared death. “No patient that I have spoken to wishes to die in pain, alone, or hooked to a ventilator,” Ravi said, “and yet that is the way in which many patients pass away in the ICU.”

Seeing similar confusion about the ballot measure among his peers, Ravi and fellow fourth-year Grant Smith helped organize a panel discussion for all local medical students earlier this month at Harvard.

It let the audience pepper panelists on each side of the issue with questions, and also use the teaching tool of a case study: A hypothetical elderly man with metastatic cancer who comes to his doctor asking for a lethal prescription.

That case discussion, Ravi said, brought out a valuable consensus among the opposing panelists: All agreed on the need for more and better end-of-life discussions with patients.

But on the “toughest question” — “Ethically, is this right for doctors to do?” — there was no clear answer, he said. Rather, each side argued that its position represented the true embodiment of “Do no harm.”

‘This conversation involves an irresolvable dilemma.’

If Ravi and his fellow students remain conflicted, they can at least be comforted that they are in plenty of good company.

By all indications, the ballot measure presents an extraordinarily difficult problem of medical ethics — a problem wrestled with nationally as states consider physician-assisted suicide laws. Thus far, only Oregon and Washington have passed them; polls suggest that Massachusetts may be next.

The ethical issues involved are hard and deep enough to divide not just medical associations but medical staffs — a Massachusetts General Hospital panel presented arguments for and against Question 2 earlier this month — and seasoned ethicists.

Consider the Boston-based Community Ethics Committee, a group of 18 diverse volunteers who gather to craft opinions on some of the thorniest of bio-medical issues.

They’ve managed to reach consensus on whether children’s organs can be donated after cardiac death but before full brain death; on social media use in medicine; and on whether medical staffers can sometimes refrain from resuscitating a patient even against family wishes. They’ve dealt with death before, on the issue of “continuous deep sedation” near the end. (Note to my family: Sounds good to me.)

But on Question 2, for the first time, they could not come to complete agreement, said the group’s founder, Carol Powers.

The Boston-based Community Ethics Committee

Instead of issuing a pro or con opinion, they put out a carefully considered White Paper that conveyed their dialogue on issues both practical and philosophical. They are also encouraging people with questions to come to a free public forum on Question 2 on Oct. 25 at Harvard. (Details here.)

The group did agree that the language of Question 2 is loaded. “Death with Dignity or Physician Assisted Suicide – neither term is both precise and fair,” the White Paper says. They decided to use “Choosing Medically Induced Death.” But otherwise, they ultimately concluded:

This Conversation involves an irresolvable dilemma. How does our society honor the choice of a terminally patient who wants to control the when, how and where of that most personal expression of a life – choosing a “good death” – while at the same time how does our society protect those among us who are most vulnerable from societal pressures to choose death and “so decrease the surplus population.”

“No amount of talking was going to make us come to one position or another,” Carol said.

The committee, aimed at community input into medical ethics, does not include doctors, but its members have spoken at various fora on Question 2, she said, and responses from doctors have been fascinating and sometimes surprising.

From a group of palliative care physicians, she heard that though they have the most expertise relevant to Question 2, they don’t want to take any sort of lead on it, because for the last 15 years they’ve been fighting the kinds of negative perceptions that prompt nurses who see them to ask, “So who’s dying?”

(Wikimedia Commons)

On the other hand, she said, among doctors who specialize in patients with disabilities and might thus be expected to oppose the measure, some have been very much for it.

The comments of one doctor, “a saint” who works with medically fragile patients, particularly struck her: “Even though he could understand the arguments for it — that there’s a sense of not only respecting a patient’s autonomy but that it can be construed as an act of compassion and care — he said to be honest, he could not imagine writing the prescription.”

“He just could not take that step mentally.”

The crux of the dilemma for doctors, Carol said, may be that if a patient can ask for a lethal prescription, “that changes the whole patient-physician relationship.”

In effect, the doctor’s role “has been reconceived,” said Prof. Dan Brock, a proponent of Question 2 and, until recently, the longtime head of Harvard Medical School’s ethics division. “It’s not always to extend life no matter what,” and that makes it more complicated.

He offered this context: Beginning in the 1960s, as life-sustaining treatments began to improve, they spurred a movement to give more end-of-life control to patients and their families, focusing largely on the ability to withdraw treatments that keep dying patients alive, such as respirators or kidney dialysis.

“I view the physician-assisted-suicide issue as, in a way, the culmination of this long process,” he said, “because it covers patients for whom there is no life-sustaining treatment to be withdrawn.”

“It’s supported by the same ethical values or principles that underlay the whole trend,” he said, “namely the importance of patient self-determination about what happens at the end,” and the recognition that in some cases, treatment may no longer benefit the patient.

Concerns about ‘playing a much more active role in the patient’s death.’

It has become an accepted part of medical practice that patients have a right to refuse life-sustaining treatment such as a respirator, Prof. Brock said. And yet on Question 2, some doctors  express concerns about “playing a much more active role in the patient’s death. They’re providing the means for bringing about the patient’s death” rather than just letting the disease kill them. They feel that “‘We’re no longer healers, we’re now killers or enders of life.’”

“In fact,” Prof. Brock said, without getting into a long ethical argument, “a physician is in a much more active role in bringing about the end of the patient’s life when he or she removes a respirator on a clearly respirator-dependent patient. My own view is that when the physician does that, the physician kills the patient, though justifiably.”

(Alex E. Proimos/flickr)

Question 2 raises myriad such issues and concerns about the potential effects of this change in the doctor’s role. Oregon and Washington can provide helpful data on how the laws play out, but that still doesn’t make it an easy call in Massachusetts.

There seems to be easy agreement on only one point: It’s good that because of Question 2, people all over are discussing dying more than usual — and that includes doctors.

“No matter whether it passes or not,” Carol Powers said, “people are going to be talking about this, and that is a very good thing.”

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Further reading:

The Community Ethics Committee’s White Paper: Choosing Medically Induced Death

On Point: Death on Demand

The text of Question 2

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  • Matta Temujin Reddy

    If you want to make euthanasia a choice, then some other professional must be trained in that aspect along with counsiling, mental status examination, financial matters before their death etc should do it. doctors should not do it…

  • Matta Temujin Reddy

    In my opinion NO………..The motto of medical profession is “Do No Harm”.
    The duty of a doctor is to heal a patient.
    patient autonomy is limited to the choices we give them, it is not like we are going to give everything they ask say a controlled substance.
    The current approach of giving as much pain relief as possible that might sometimes hasten death is a better policy.

  • Shelley Fitzgerald, D.V.M.

    The issues raised by this ballot question are faced by veterinarians every day. I can only speak for myself but I can say I have never enjoyed euthanising a client’s pet. However, I am glad the option is available.
    The word euthanasia means ‘good death.’ Perhaps veterinarians’ experiences could provide some clarification.

  • Lewis Cohen, MD

    Congratulations on an unusually lucid discussion of this complex subject. As one of the initiators of the ballot question, I am obviously a proponent. I’m incensed when encountering one of the opposition’s fear-mongering television commercials – which will only increase as Election Day approaches. The foes of Death with Dignity are mainly the same people and organizations that fund campaigns against same-sex marriage, pro-choice, and freely available contraception, and they have amassed a war chest of over $1 million to fight ballot question #2.
    By way of contrast, this article taps into the legitimate ambivalence that thoughtful physicians experience as they contemplate assisted dying. Medicine’s advances have paradoxically forced doctors and nursing staff to confront the meaning of “do no harm” and their personal Hippocratic Oath.
    It is worth noting that the original oath is 2500 years old and definitely shows its age. It begins, “I swear by Apollo Physician and Asclepius and Hygieia
    and Panaceia and all the gods and goddesses.” The oath includes a prohibition against assisted dying, as well as performing abortions, and historians suggest that it was written in reaction to the commonly accepted practices of the previous generation of physicians. In a modern version of the oath written in 1964 by the late Dr. Louis
    Lasagna, Academic Dean of the School of Medicine at Tufts, one can find considerably more compassion, nuance and humility than old Hippocrates. Lasagna’s oath deletes these prohibitions and instead includes the injunction: “I will apply, for the benefit of the sick, all measures [that] are
    required, avoiding those twin traps of overtreatment and therapeutic nihilism.”
    I’m pleased that Ravi Parikh and his fellow medical students are actively trying to sort out these issues. While they won’t have an opportunity to truly face them unless the ballot question is passed, I’m glad they are thinking and discussing.

  • eddie

    It is good to have public discussion about a very important issue.

    I thought that I would be in favor of the question, but i was to be disappointed.
    There are at least 40 different regulatory steps to this process, most of which require documentation, and reports to the state.

    A very private process between physician and patient is in danger of spawning a new state agency. Their function may grow from recording to advising to demanding that things be done in such a manner.

    Finally section 18.3.b. and c.
    Your lawyer will need to be involved to be sure that you are in compliance with this section. This is the classical small print that can get you in trouble

    • lokicat3

      I served until recently as a hospice chaplain. In my six years in this work, I was often surprised by family members bursting out with their true feelings and say “you wouldn’t let a dog suffer like this.” Patients would say, “I just want to die” and “why doesn’t God take me?” Now, probably all these people did not hasten their deaths, but the point being, is their strong concern for the suffering and even agony of those who deserve a choice.
      The other point is that although pain remediation is better now, it is still not 100% by any means. Despite the great skill and caring of a hospice or palliative care team, no one is guaranteed a peaceful death. I personally believe in in this choice, although in my role as chaplain, I’d just listen and didn’t express my point of view, I think they knew I agreed with them.

  • CircusMcGurkus

    The medical community is utterly unclear about the meaning of the word “ethics”. Ethics seeks to evaluate moral duty, responsibility and obligation. At a minimum, the patient’s wishes, particularly one with the gift and burden of knowing death is near, must factor in when deciding medical ethics. Imposing one’s values on others is NOT ethical.

    100% of the residents of Oregon die, which is the exact same statistic
    of every other place in the world. But, in Oregon there are more
    choices, more and better hospice care services and much more dignity in
    the process. Yet, even in Oregon most patients who choose physician
    assisted suicide – which is a relatively small number – ultimately do not swallow the pill. Just knowing they
    have it there gives them comfort.

    We need to recognize that doctors do not “save” lives. At best, they may prolong lives. But, prolonging another’s life to put off the “failure” of a patient’s death is immoral. The patient is going to die. We all are going to die. The issue has NOTHING to do with preventing death.

    Indeed, the cost of end of life care – that many do not even want – inhibits the ability of doctors to help people who can actually benefit from their care. While the conversation about limiting end of life care must occur, that is not what this bill would do; it is not “rationing care” when it is patient directed. It is not promoting death when every single thing that can be done has been done and despite those heroic efforts, death is coming anyway.

    Shame on MA doctors for not supporting something just because death makes them uncomfortable. Shame on them for not supporting medical marijuana because it is “not proven” to work. Who cares? If it helps the patient, then it is working. When nothing more will work and the patient has come to terms with his own end, the most compassionate thing for doctors to do is allow the patient to make the decision, or at a minimum, refer them to a doctor who will. Everything else is nonsense and ego.