THE ULTIMATE QUESTION JANUARY 8, 1997 TRANSCRIPT

The Supreme Court is considering arguments over whether physicians may assist terminally ill patients in committing suicide. Lower Federal courts have already thrown out laws in New York and Washington State that prohibit the practice. But Justice Department lawyers believe legalizing assisted suicide could lead to abuses. Rod Minot of KCTS-Seattle provides a background report, followed by a discussion with doctors for and against changes in the law, and Margaret Warner. MARGARET WARNER: To debate the medical and ethical issues raised by today’s Supreme Court cases we have two physicians. Dr. Ira Byock is a practicing hospice doctor in Missoula, Montana, who specializes in caring for patients in the last months of their lives. He’s also president of the American Academy of Hospice & Palliative Medicine. Dr. Marcia Angell is the executive editor of the New England Journal of Medicine. She wrote a recent editorial supporting physician-assisted suicide. For the record, Dr. Angell has said that the editorial reflected her own position and not necessarily that of the Journal. Welcome both of you. Dr. Angell, you support a patient’s right to have a physician assist him or her in suicide. Give us the medical and ethical dimensions of that from your perspective. DR. MARCIA ANGELL, New England Journal of Medicine: Well, it seems to me almost self-evident that a dying patient who is suffering unbearably should have the option to end his life. And most such patients will require the assistance of a doctor to do so humanely and with dignity. We’re not talking about forcing such patients to end their lives, and we’re not talking about requiring doctors to help them. We’re merely saying that there should be this choice, that they should be able to exercise the option. MARGARET WARNER: And you said that patients needs a doctor to do this. Why? DR. MARCIA ANGELL: Well, in most cases patients will want a doctor. Not every patient knows how to get hold of the pills or how many pills he should take. They’re afraid of botching the job. And, of course, the very illegality of it means that it’s often done badly. It’s often done violently. The doctor’s been with the patient this far in a terminal illness. And I think the doctor has an obligation to help the patient in whatever way seems appropriate all the way through the lingering illness. MARGARET WARNER: Dr. Byock, you think this is a very bad idea. Why? DR. IRA BYOCK, American Academy of Hospice and Palliative Medicine: Well, I think it mischaracterizes the experience of dying. Dying is not easy and it’s not fun but the suffering that people experience can be alleviated. I’ve been doing hospice work for some 18 years, and I’ve yet to meet a patient whose physical suffering could not be dramatically improved. There is not this wealth of people whose suffering, whose pain and breathlessness and the like we cannot treat. There is, however, a large amount of patients whose suffering is not adequately treated. That’s true. The fact is that medical care for the dying at the present time is frankly terrible. And that’s not only supported by anecdotes that we all, clinically and through our own lives, but a number of research studies now show that care of the dying is largely deficient. This is not the time to begin expanding the power of physicians. The other thing is that patients now do not often have a physician who sees them through a long illness. Our system is significantly broken, and I’m afraid that while there’s a crisis in end-of-life care in America, its roots are being left untouched by what is being proffered as sort of a quick fix to what is a very serious and deep problem. MARGARET WARNER: Dr. Angell, I want you to respond to those points, but first let me just ask you as a factual matter, what are the dimensions of this crisis in end-of-life care? Does the medical community have any idea how many physicians, for instance, are asked by their patients for help in committing suicide? DR. MARCIA ANGELL: Well, assisted suicide is a crime in most states in this country, and it’s very hard to get accurate statistics about a crime. People aren’t going to respond to a question like: Did you commit a crime? The best evidence we have comes from a survey of Washington State physicians that found that about 12 percent of them have been asked, or said they have been asked by their patients to help them end their lives, and about 1/4 of those said that they had complied with these requests. We also know that many doctors give very large doses of morphine at the end of life, ostensibly to relieve pain and breathlessness, but also in many cases to hasten death. There’s a lot of subterfuge and doublespeak here. And, of course, it is legally permissible to withdraw life support from dying patients. MARGARET WARNER: And was Lawrence Tribe, as we just heard described in the arguments today, was he right when he said, from your experience, that a lot of doctors do prescribe tremendous barbiturates say to patients, then withdraw the life support, and the patient dies in this coma? DR. MARCIA ANGELL: That happens. MARGARET WARNER: Do you agree, Dr. Byock, with what she just said, that a lot of this, that it goes on to this extent, and that it does go on sort of under the table? DR. IRA BYOCK: I agree that a number of patients are interested in suicide, and those of us who practice in end-of-life care hear requests all the time. We respond to those requests. When a person voices an interest in suicide, I want to know why, what the source of their suffering, what the nature of their suffering is. If it’s pain, we need to treat that. If it’s something else, if it’s some fractured relationship that is unhealed in their life, or if it’s some existential question, there is care for that as well. This is not an easy matter, but it can be done. And it takes more than a doctor and his or her patients. It takes a team of people working in a system to do it, but it can be done. It’s true that we use morphine and other opiate-like medications, narcotic medications to treat pain, and it works effectively. It can be done in all cases. We can’t always take away pain, but we can make it tolerable. MARGARET WARNER: Are you saying that you think really that you disagree with the premise that even the patient has the right to say, I know you can do a lot of things for me, but I’ve reached the end of the road and I want to go? DR. IRA BYOCK: Well, it’s--there are some limits appropriately on the doctor-patient relationship. We put limits on the doctor-patient relationship in a number of different matters as well, appropriately. We’re talking about medical practice and policy in a social context. We have a social context now where we know that in advanced cancer, for instance, as much as 40 or 50 percent of patients do not get adequate basic pain relief at the end of life by World Health Organization standards. We also have a system that routinely punishes patients and families financially simply for being seriously ill and not dying quickly enough. We have a country that three years ago said there was no right to health care, and now it seems the wrong time to expand the medical profession’s right to assisted suicide and declare there’s a constitutional right to die when you’re sick enough. MARGARET WARNER: All right. Dr. Angell, respond to the first point he’s made actually a couple of times, which is there really shouldn’t be any need for this; that doctors could manage pain better, that there are plenty of other alternatives other than suicide. DR. MARCIA ANGELL: Well, I certainly agree that our care of the dying is inadequate and that comfort care should be better, and we should redouble our efforts to treat patients’ symptoms at the end of life aggressively. But this is not mutually exclusive with permitting physician-assisted suicide in those cases when good comfort care is inadequate. Right now we have neither good comfort care nor the availability of assisted-suicide. I think we should have both--good comfort care for most dying patients and the availability of assisted-suicide for the relatively few patients for whom comfort care is inadequate. MARGARET WARNER: So from your experience do you think that even if comfort care were better there would still be people seeking this? DR. MARCIA ANGELL: Oh, absolutely. Not all pain can be relieved, and other symptoms, such as breathlessness and nausea and weakness are even harder to treat. And we know that there are patients at the end of life who are having good comfort care who still wish to end their lives. MARGARET WARNER: Let me go back to the other argument you made and just get you to expand on it a little bit, when you talked about financial pressures. Do you--are you saying that you think if this were to happen that there would be financial--pressures on patients to choose this option from people other than themselves? DR. IRA BYOCK: Well, there already are pressures. People who are approaching the end of their lives see the medical bills. They see then shortly thereafter the default statements. Our system routinely pauperizes people in the process of caring for them, so it seems like it’s a self-determination because they will ask for the help themselves, but they do it out of the sense of being a burden to themselves and then their families. It’s--our system is broken. It can be fixed, by the way. The roots of this problem are complex, but there is a solution available, and it involves making truly excellent end-of-life care available. I have been working in this realm for a long time. I have yet to see the patient whose suffering we could not make significantly better. It involves more than just morphine and more than just a doctor. It involves a real commitment on the part of a system to address the needs of people. People suffer from the pain, obviously, when it’s untreated. They suffer from the sense of being a burden, of being hopeless. They also suffer from isolation. So in addition to good medical care, it involves companionship, sitting with people in a caring way, perhaps in silence, but perhaps oiling their skin and massaging them and just letting them know we’re around and here and will be with them, care that can honor, even celebrate, the person in their passing. That takes it out of just the realm of medicine. I’m afraid that this quick fix that’s being offered will act as an escape valve, allowing the profession of medicine, which really needs some real remedial help right now, a way to continue to avoid the deep roots of the problem. DR. MARCIA ANGELL: This isn’t about the profession of medicine. This is about patients, about individuals who have to make these judgments for themselves. We can’t say, oh, yes, we can take care of you, we can make your pain go away; tell us that your pain has gone away. The pain may still be there. The dyspnea, the hopelessness may still be there. My father committed suicide at the age of 81. He had cancer of the prostate, metastatic cancer of the prostate. He had received hospice care. He found it inadequate. He was suffering not so much from pain but from these other symptoms--from nausea, from weakness, from hopelessness. And he decided it was time to end his life. He did so, in fact, the day before he was scheduled to be admitted to the hospital. He did so then because he thought he would lose the chance once he got in the hospital. And so he took a pistol, and he shot himself. I don’t think that this should have had to happen. I would rather have seen him have the option of taking pills that had been legally prescribed for him by a doctor, have them at his bedside, rather than the pistol, and take them later, if and when he wanted to. MARGARET WARNER: All right. Dr. Angell and Dr. Byock, thank you. We’ll have to leave it there. DR. IRA BYOCK: Thank you. THE ULTIMATE QUESTION JANUARY 8, 1997 TRANSCRIPT