Transcript Death With Dignity Act

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
Outline
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Define Physician Aid-in-Dying (PAD)
History of PAD
Arguments Against PAD
Arguments in Favor of PAD
Weighing the Arguments
Oregon’s Death With Dignity Act
Making up One’s Own Mind:
An Ethical Framework and Three Case
Scenarios for Small Group Discussion
What is Physician Aid-in-Dying?
Modeled on Oregon’s Death With
Dignity Act
As Set Out in California’s AB 654
A Process to Request Life-ending
Medication
Oregon’s Death With Dignity Act
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
Requirements for Lethal Medication
Two Oral Requests
A Written Request
A Confirmed Diagnosis & Prognosis
Patient Must be Capable
If Judgment is Impaired, the Patient
Must be Referred
Must be Informed of Alternatives
Notification of Next of Kin
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—9th and 2nd Circuits Courts of Appeal rule State
Prohibitions on P-A-D Unconstitutional
1997—The Supreme Court Reverses, But Leaves the
Door Open
1997—Oregon’s Measure 16 Reaffirmed by 60/40
1998—Measure 16 Becomes Law in Oregon
2004—Ashcroft Moves to Criminalize the Prescription of
Medicine that “Will Result in Patients’ Deaths.”
2005—Gonzales v. Oregon appealed to Supreme Court
2005—California’s AB 654 now Moot
Arguments AGAINST PAD
Religious
The CMA
Many Palliative Care & Hospice Providers
The Lobby for the Disabled
Arguments IN FAVOR of PAD
Religious
Many Oncologists and Nurses
Many Patients
Patients’ Advocacy Groups
Weighing the Arguments
1. The Religious Debate
Absolute Sanctity vs. Quality of Life
The Roman Catholic Prohibition
The Biblical References to Suicide
The View of Moderates
Weighing the Arguments
2.Tension Between the Medical Mandate
Not to Harm and Alleviating Suffering.
Between the Ethical Principles of:
Beneficence and
Nonmaleficence
Weighing the Arguments
3. Dying Invested with Meaning
Pain is Manageable
Not Possible to Relieve All Pain
Difference Between Pain and Suffering
Weighing the Arguments
4. The Slippery Slope Argument
The Simplified Form of this Argument
The Fallacy, Slippage is Not Automatic
Oregon’s Record Speaks for Itself
There has not been any slippage
Oregon’s Death With Dignity Act:
Facts and Commentary
1998
1999
2000
2001
2002
2003
2004
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 Medications
16
27
27
21
38
42
37
Number Not Ingesting
Medication
8
6
12
23
20
26
23
5.5
9.2
9.1
7.0
12.2
13.6
12
Ratio of PAS Deaths to
Every 10,000 Total Deaths
Figures from the Seventh Annual Report on Oregon’s Death With Dignity Act
Oregon’s Death With Dignity Act:
Facts and Commentary
Since the Death With Dignity
Act was Implemented:
49% of PAD patients used secobarbital
50% used pentobarbital
2% used either
secobarbital/amobarbital or
secobarbital/morphine
Oregon’s Death With Dignity Act:
Facts and Commentary
Most Frequently Reported Concerns:
Decreased Ability to Participate in
Activities that Make Life Enjoyable
(92%)
Losing Autonomy (87%)
Loss of Dignity (78%)
Oregon’s Death With Dignity Act:
Facts and Commentary
Patients Requesting PAD Suffered from:
Malignant Neoplasms (79%)
Lung and Bronchus (19%)
Breast (9%)
Pancreas (6%)
Colon (6%)
Other (36%)
Oregon’s Death With Dignity Act:
Facts and Commentary
Patients Requesting PAD Suffered from:
ALS (8%)
Chronic Lower Respiratory (5%)
HIV/AIDS (2%)
Oregon’s Death With Dignity Act:
Facts and Commentary
Of Physicians Who Complied with
Patient Requests for PAD:
57% Practiced Family Medicine
22% Were Oncologists
8% Were Internists
70% Wrote Only a Single
Prescription
Oregon’s Death With Dignity Act:
Facts and Commentary
A Request for PAS Can:
Be an Opportunity to Explore Fears
and Wishes Around End-of-Life Care
Make Patients Aware of Their Options
An Ethical Framework
Elements in Making Up One’s Own Mind:
Acquire As Much Factual Information
as Possible
Identify Beliefs and Values
Apply the Principles of Biomedical
Ethics
Factor in Data Extrinsic to the Clinical
Situation, Such as the Law
Scenario 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 field
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”. 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.”
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Scenario 1
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 had been your patient, would or would you not have done for
her what her oncologist did?
Use the ethical framework to describe the reasons for your decision.
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Scenario 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 laryngealesophageal 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.
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Scenario 2
His wife, a devout Roman Catholic, makes an appointment to see you,
says that she believes her husband is depressed, has been stockpiling 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?
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Scenario 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 had 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.
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Scenario 3
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?
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Apply the Ethical Framework
Acquire As Much Factual Information
as Possible
Identify Beliefs and Values
Apply the Principles of Biomedical
Ethics
Factor in Data Extrinsic to the Clinical
Situation, Such as the Law