BY DANIEL GAITAN | firstname.lastname@example.org
As support for physician-assisted suicide grows and state lawmakers debate legalizing the controversial practice, proponents say doctors and patients will benefit from reliable clinical criteria.
Supporters of the practice have published a report in the Journal of Palliative Medicine in support of national standards. They hope to offer a safer and more reliable experience to terminally ill people seeking to end their lives with doctor-prescribed drugs.
Researchers write that any criteria should be based on Oregon’s “Death with Dignity Act” of 1997.
“In all of medicine, people want to know what’s considered best practices,” said co-author and attorney Thaddeus Pope.
Pope, director of the Health Law Institute and a professor at the Mitchell Hamline School of Law in Saint Paul, Minn., spoke with Life Matters Media about his support for the practice, which is legal in a handful of states.
He also spoke about the importance of end of life conversations and his blog, Medical Futility.
Why is clinical criteria for physicians needed?
The mission is really for states like Montana and New Mexico, because you have two states that have legalized medical aid in dying, but they don’t have any statutes like California, Washington, Oregon or Vermont. There are no standards for eligibility. There are no standards for anything.
The idea is that this would fill in the gaps, that this will fill in the vacuum. There’s no legislation, there’s no regulation, there’s just really a court decision. That’s the mission, to help provide some guidance when the official state law does not.
Why would physicians practicing in states without established ‘Death with Dignity’ programs want guidance?
In all of medicine, people want to know what’s considered to be best practices. You want to have a sense that, ‘this is what’s been done before,’ ‘this is what’s safe,’ ‘this is what’s effective.’
We published the review based on the experiences of Oregon and Washington. This is what they have been doing for 30 years, and we haven’t seen any problem. It gets these people what they want.
It’s sort-of a risky thing, or it is perceived to be a risky thing. It’s a little bit of an unusual practice. People want to know that the way in which they’re doing this is reasonable or considered to be professionally responsible and ethical.
(Guidance) provides reassurance that, ‘Yes, this is the best that we’ve come up with.’ Especially if your state medical board hasn’t spoken, your state legislature hasn’t spoken.
Is there anything you would personally like to see change in Oregon’s “Death with Dignity Act”?
Every state, including the new California statute, requires that there is only a mental health screening on referral.
There’s no psychiatrist or psychologist or any other mental health professional that’s going to screen, do any assessment, to make sure that the patient has the capacity to (request and ingest life-ending drugs). Only if the attending or consulting physician thinks they need that will they get it, and that hardly ever happens.
The referral rate is so low, but we know that the rate of depression, and it’s not just depression, it has to be depression that actually impairs your judgement, could be a significant rate.
We know that general physicians are not really trained or good at diagnosing this stuff. There’s a reason to think that there are people who are impaired who are still able to do this. Nobody thinks that that’s good. It’s not clear that we’re ensuring that all the patients who are getting this are making a voluntary or informed choice.
But I’m not sure I would change anything, because I would need to know what the costs are. Require mental health assessments straight up?
Already, Vermont, Washington, Oregon and California require two physicians to certify patients: the consulting and the attending. One thing to consider is to have the attending physician, the consulting physician and add the mental health assessment automatically.
I’m sure there’s a counter-argument that this would cost money or take too long.
However, I don’t really have many other concerns. Everybody around the world is considering this. I think if you do it the same way as Oregon or Washington, other states should have no problems. The mental health thing is the only thing I would think about changing.
Why do you think more state legislatures are considering “Death with Dignity” legislation?
I think it’s a snowball effect. Once it gets going, it seems reasonable and possible in other states.
The other big thing: We pay more attention in general to end of life issues. We changed the Medicare rules this year to pay for advance care planning. We, as a society, are more on board with actually confronting the fact that we are all going to die. We have heightened awareness and acceptance of all these issues.
Aid-in-dying is a very small issue. Only 0.4 percent of the people that die each year use this as the means to hasten their death. So it’s a little bit odd that state legislatures, all these debates, all this attention is spent on this.
But one of the big benefits of the focus on aid-in-dying is that it causes us to talk about dying more generally. It raises the profile for the ways in which the other 99.6 percent of the population is going to die.
Hospice, intensive care units, palliative care end up being talked about. Every state legislature that debates aid-in-dying will say, ‘Do we need this? What about hospice?’ The public conversation in itself is a value.
What inspired you to launch your blog, Medical Futility?
My first big issue was medical futility disputes, which is where it gets the name. I noticed that this was a very big issue in intensive care and clinical ethics. Conflicts are so common and take up so much energy.
But there really wasn’t a lot of discussion going on in the literature. When I was researching, I wanted to start a conversation, not wait months for a medical journal. It’s very selfish in one sense. It’s just a way for me to explain things to myself and make it public.
The good news is that at least among bioethicists, it’s probably the thing that people know about me. It gets me more visibility than anything else.