Fourth state allows physician aid in dying: Is it an affront to palliative care?
Vermont, Oregon, Washington, and Montana now allow physicians to prescribe lethal doses of drugs to terminally ill patients who meet certain criteria and request lethal prescriptions. Some ethical concerns:
- Publicity over physician aid in dying could result in misconceptions about end-of-life care.
- Patients often don’t realize that palliative care is a much broader concept than physician aid in dying.
- The laws don’t necessarily change the practice of individual physicians, who are free to conscientiously object.
Publicity stirs debate over end-of-life care
With Vermont becoming the fourth state to allow physicians to prescribe lethal doses of drugs to terminally ill patients who request prescriptions, along with Oregon, Washington, and Montana, it is possible that other states will follow suit or increase advocacy efforts.
"Legalization in Vermont has both positive and negative implications for end-of-life care," says Robert Macauley, MD, medical director of clinical ethics at Fletcher Allen Health Care, and professor of pediatrics at the University of Vermont in Burlington.
"In terms of the positive, the debate surrounding physician-assisted dying has thrust end-of-life issues into the public consciousness. It has made possible nuanced and thoughtful conversation," he says. "In terms of the negative, I worry that the surrounding publicity may cause some people to reduce palliative care to physician-assisted dying only."
At a recent community educational event in Vermont about end-of-life care, the majority of the questions related to physician-assisted dying, says Macaulay, and seemed to overlook the fact that palliative care is a much broader concept. Macauley hopes bioethicists will take advantage of opportunities to emphasize that no one — neither physician nor patient — is obligated to utilize physician-assisted death, and that symptom management, advance care planning, and patient empowerment can often resolve the concerns that prompt patients to inquire about hastened death.
"I firmly believe that Doctor, will you help me hasten my death?’ is not a yes or no question, based on the moral position of the physician," says Macaulay. "Regardless of whether one believes that physician-assisted dying is moral or not, such a question should prompt further inquiry as to what is driving the patient to make such a request and in what ways the physician can be of assistance."
Keith M. Swetz, MD, MA, associate professor of medicine at Mayo Clinic in Rochester, MN, says that while the legalization of physician-assisted dying in four states has received much publicity, it doesn’t necessarily change the fundamental goals of medicine.
"That is to provide the best care to the patient that you can during a time of need. If one state or another chooses to enact a law, that doesn’t change that," he says. "A major reason for people pushing through laws that deal with physician-assisted dying really has to do with control and not inadequate care."
Just because a law is passed doesn’t necessarily mean the practice of individual physicians will change, adds Swetz. "Oregon and Washington have their systems in place, and Montana is still wrestling with how to enact the law," he notes. "It’s important to note that physicians have the right to conscientiously object to anything they personally see as being objectionable."
A slippery slope
"I think most palliative care providers see physician-aided dying as an affront to palliative care," says Swetz. "Under what circumstances would physician-aided dying be desired? If a patient’s symptoms are managed and the patient is not suffering quality-of-life issues, then generally the request is the person’s own preference or their desire to die on their own terms." (To view the American Academy of Hospice and Palliative Medicine 2007 position statement on physician-assisted dying, go to http://www.aahpm.org/positions/default/suicide.html.)
The 2011 documentary film How to Die in Oregon covers the state’s Death With Dignity Act, including interviews with many people who opted for physician-aided dying. Swetz says that he was struck by the fact that many individuals featured in the movie had a clear lack of palliative care. "The film has a very strong focus on individual rights, versus other ethical systems that would look at the good of the person and the community," he adds.
Some providers have made efforts to differentiate palliative care from euthanasia, notes Swetz, and to show that palliative care is not associated with the hastening of death in any way.
"Outside of the United States, there are still concerns that not aggressively intervening on life-threatening illness and focusing on palliation only may be viewed as allowing to die, which some see as passive euthanasia,’" Swetz adds, "It is an important role of the bioethicist to point out that there is a moral difference in killing and allowing to die."
In most cases, palliative care has the ability to reach beyond end-of-life care and focus on caring for a patient throughout the course of illness, says Swetz, adding that this is a key educational role that all health care providers, particularly those in bioethics, have an opportunity to promote.
"There is a concern that as physician-aided dying becomes more mainstream, that people may question the motives that can occasionally be in conflict with one another," Swetz says. "When these issues are brought up, there is a natural tendency to lump things together. But they are not the same."
Swetz notes that there is still a very strong sentiment against using appropriate opioids to help people to be comfortable. "That issue still needs to be worked on. Being that there are legal prescriptions with the specific purpose of hastening death, people who do not know the facts may blend the two together," he says.
Cost-containment efforts
Some Oregon patients have claimed that their health insurance would not pay for expensive chemotherapy treatments to treat advanced cancer, but agreed to pay for physician-aided dying and associated medications. "It can be a slippery slope," says Swetz. "This becomes a question of whether we are going to legislate cost containment by having these policies available. Even if we are not, people might perceive that physician-aided dying is associated with trying to contain costs."
Patients and family members who are offered palliative care are sometimes concerned that providers aren’t being aggressive with treatment because of cost-containment issues. "There is a concern that society may think of palliative care as another measure to contain costs and ask, Is this option being given to me because people don’t want to spend money on my medical care?’" he says. "It could be totally untrue, but it can be a perception issue."
Any patient’s request for hastened death is an opportunity to enter into a meaningful dialogue and address a person’s fears or unanswered questions, underscores Swetz.
"If a patient requests physician-aided dying, there is often an unmet need or suffering on some level which may not be optimally treated," he says. Such requests allow clinicians — whether palliative care providers, nurses, or clinical ethicists — to ask why a person is making such a request and to explore if there are other alternative treatments that can meet a person’s goals of care without only providing a lethal prescription.
"From an ethical perspective, I think it is critical for clinicians and ethicists to acknowledge the biases that come with holding personal moral beliefs, while striving to inform and empower patients to make their own decisions," says Macauley.
This means presenting patients with all relevant and legal options, and at the same time, acknowledging that no patient or physician is obligated to take part in physician-assisted dying, even if it is legal. "In states like Vermont that have legalized physician-assisted dying, there continue to be significant ethical issues," says Macauley. "The conversation is shifting from whether it should be legalized, to how the medicine should be practiced now that it has been."
- Robert Macauley, MD, Medical Director of Clinical Ethics, Fletcher Allen Health Care, Burlington, VT. Phone: (802) 847-2000. E-mail: [email protected].
- Keith M. Swetz, MD, MA, Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN. Phone: (507) 284-9039. E-mail: [email protected].
