Ethical Issues in Medical Oncology: Physician Aid-in-Dying

1. 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

2. Outline • 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

3. 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

4. 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

5. 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

6. 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

7. Arguments AGAINST PAD • Religious • The CMA • Many Palliative Care & Hospice Providers • The Lobby for the Disabled

8. Arguments IN FAVOR of PAD • Religious • Many Oncologists and Nurses • Many Patients • Patients’ Advocacy Groups

9. 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

10. Weighing the Arguments 2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of: • Beneficence and • Nonmaleficence

11. Weighing the Arguments 3. Dying Invested with Meaning • Pain is Manageable • Not Possible to Relieve All Pain • Difference Between Pain and Suffering

12. 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

13. Oregon’s Death With Dignity Act: Facts and Commentary ---------No Figures Available-------- Figures from the Seventh Annual Report on Oregon’s Death With Dignity Act

14. 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

15. 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%)

16. 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%)

17. Oregon’s Death With Dignity Act: Facts and Commentary Patients Requesting PAD Suffered from: • ALS (8%) • Chronic Lower Respiratory (5%) • HIV/AIDS (2%)

18. 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

19. 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

20. 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

21. 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.” Page 1

22. 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. Page 2

23. 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 laryngeal-esophageal 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.  Page 1

24. Scenario 2 His wife, a devout Roman Catholic, makes an appointment to see you, says that she believes her husband is depressed, has been stock-piling 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? Page 2

25. 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.  Page 1

26. 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? Page 2

27. 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