Arguments Against Ballot Question 2: Brigham and Women's Hospital Center for Bioethics Rounds

Following is a transcript of remarks delivered on October 23, 2012, by MMS Presidient Richard V. Aghababian, MD, at Brigham and Women's Hospital's Center for Bioethics Rounds.

As the current president of the Massachusetts Medical Society, I'm here to share the policies that my fellow members and I have crafted after extensive debate on this matter. I will attempt to explain the reasoning for our policy.

Our House of Delegates examined this issue very carefully in the past year, as we have since several times since 1999. We did not arrive at our decision hastily. We had considerable debate, but in the end, the vote clearly demonstrated a lack of support for physician-assisted suicide.  I believe that we all came away with respect for both sides of the issue. A description of our position on physician-assisted suicide has been posted on the Medical Society's website, and mailed to all of our Massachusetts-based members.

We all understand that medicine's treatment of patients at the end of the life remains problematic. For example:

  • A disproportionate amount of the health care dollar is spent during the last year of life. Some feel that some of this money could be used more wisely.
  • The so-called "death panel" debate three years ago unfortunately short-circuited any meaningful discussion at the national level about end of life care.
  • Pain at the end of life may not be always well-recognized by patients and doctors. Therefore, treatment may be suboptimal.
  • The use of hospice services, where available, may not be requested by physicians, or utilized by patients.
  • As the end of life approaches, family members can be at odds with each other, and sometimes even at odds with the terminally ill patient. They may demand the continuance of futile care.
  • Patients may have neglected to make their end-of-life issues well known to their doctors and their family members.

The Massachusetts Medical Society recognizes that there is a lot of work to be done - and not just by those of us in medicine. However, these shortcomings do not justify support for Question 2. They compel us to improve end of life care, not abandon efforts by making the patient feel that suicide is a viable option.

I want to outline the five principal reasons for our opposition to Question 2.

The first reason: The proposed safeguards in the legislation are not sufficient. The safeguards may sound impressive, but there are several loopholes that are troubling. There is no provision to enforce the proposed safeguards, and there is no oversight over the process; only a statement that punishment will follow criminal behavior.

There is no authority given to any state agency to investigate suspicion of wrongdoing.  The only check against abuse is the opinion of the prescribing doctor, which puts the physician in the role of both caregiver and law enforcement officer. This is not appropriate. It's one of the many subtle ways this proposal could undermine the patient-physician relationship. Worse, physicians are held only to a "good faith" standard. This makes any or all of the safeguards unenforceable.

Another issue is the fact that one of witnesses to the patient's signing of the document declaring his or her will to implement this procedure may be an heir of the patient. This opens the door to the possibility of abuse, even though one of the other witnesses may not be an heir. Why allow any heir to be a legal witness to the signing? And finally, there is no requirement that there be an independent witness to the administration of the legally prescribed suicide medication.

The second reason for opposition the question is that assisted suicide is not necessary to improve the quality of life, at the end of life. Currently, a patient is legally and ethically free without assistance to refuse lifesaving treatment, or to insist on adequate pain medication. They need no one else's help to do so. If the patient is unable to speak for himself or herself, a health care proxy can do so on their behalf.

Proper advance directives, which are legally binding in Massachusetts, can address many issues about quality of life at the end stages of a disease. Palliative and hospice care are wonderful resources that are not utilized at any level close to their potential. Professionals in hospice care are very skilled, very compassionate, and very wise. They serve both the patient and the patient's family, and they do so very well. Both my wife Ann and I have had very favorable experiences with hospice care when caring for our own parents at the end of their lives.

In the framework of an existing patient-physician relationship, and with appropriate documents in hand, a physician will understand the wishes of the patient, the concerns of the family, and should address these issues with great compassion and professionalism. As of today, over 98% of Massachusetts residents have health insurance.  90% have a primary care physician, and approximately half of PCPs are currently taking new patients. So there is no reason why a patient, with a diagnosis of a disease that may end their life, shouldn't have a physician to provide health care treatment and guidance.

The Commonwealth of Massachusetts currently requires that physicians receive continuing medical education on end of life care. The MMS and many other providers of CME are increasing their efforts to provide such educational opportunities.

The third reason for opposing the ballot question: Physicians' ability to accurately predict the time of time is uncertain. I think everyone in this room knows how difficult such a determination can be, especially in complex patients with multiple co-morbid conditions. It's very difficult for a physician to predict with accuracy when a patient is expected to survive six more months due to their condition. A Harvard physician, Nicholas Christakis, recently found that 17 percent of hospice patients he studies outlived their diagnosis. It supports what many suspected; it is very difficult to make such predictions.

The fourth reason: As the most recent MMS president has stated previously, physician participation in assisted suicide is fundamentally at odds with our duty to be healers. The legislation allows physicians to opt out of this practice for reasons of personal conscience. But when even some members engage in this activity, it affects us all, and fundamentally changes the dynamic of the patient-physician relationship. It may introduce the seed of doubt into a patient's mind about the motives of the physicians.

In fact, several advocacy groups for disabled patients (including a group called Second Thoughts) are very worried that this could put them in a vulnerable position, and introduce the possibility of coercion or fraud. They maintain these are vulnerable populations, and they deserve unqualified protection. You may or may not agree with this concern, but it illustrates the point that the patient-physician relationship gets very complicated under a scenario where physician-assisted suicide is legalized, and enshrined in state law and case law.

Massachusetts already has a strong vehicle that gives patients the ability to make their wishes known. Advance directives are legally binding, and can be as specific or non-specific as the patient wishes. As I have stated, often they are communicated by a health care proxy, examples of which are available on the internet. In fact, health care proxy forms have been one of the popular pages on the MMS website for many years.

As physicians, it's important for us to evaluate reliable data, before making clinical decisions. Let's look at the data from Oregon, which were provided by its department of public health. This chart (.pdf) shows the underlying illness for those who ingested the medication. The vast majority had cancer. Lung, breast, colon and prostate were the most common. The slide lists the other conditions.

The median relationship between the patient and the physician was only 12 weeks. This suggests that a large number of patients may not have had a long-term relationship with a physician who manages the terminal disease that was ultimately stated in the death certificate. This suggests that a large number of patients were cared for by a physician who specialized in providing suicide services. Do we really want to foster the growth of this kind of specialty in Massachusetts? This is not the kind of doctor-patient relationship that the MMS and the people of Massachusetts have been striving for in our own health reform initiatives, dating back to 2006.

The next data point is that only 7 percent of patients were referred for a psychiatric evaluation, even though it is well-documented that a terminal illness is often accompanied by depression. And the prescribing physician is present at death in only a minority of cases. In 2011, no provider at all was present in nine out of 10 cases. The median time between ingestion and death typically is brief, but the range is very broad - perhaps a little too broad to be acceptable.

And there have been serious treatment complications. 22 people regurgitated after taking their medication, and 5 regained consciousness. One case, a patient regained consciousness 88 hours after ingestion. Did these individuals receive humane end of life care?

Let me summarize where the MMS is on this issue. Our medical society first voted against physician-assisted suicide in 1999. At our Interim Meeting 10 months ago, we reaffirmed that position, which you seen reproduced on the screen. The 24,000 physicians and medical students of the MMS believe we need to do more to contribute to the comfort and dignity of the terminally ill patient, and the patient's family. We have rededicated ourselves to achieving that goal.

I want to close with a brief comment about one of the arguments that is sometimes posed by supporters of the ballot question. Their argument is that this issue is about patient, and that the physicians' concerns are not relevant to the debate. They say that what matters are the patient's wishes and concerns, not ours. That argument has validity, but only to a point.

We do believe that in patient autonomy. We do believe that the physician serves the patient, with the patient's interests foremost. This is, after all, the most personal of all issues. But physicians should also stand by the ethics that have been the hallmark of our profession for thousands of years.

Ultimately, it does come back to the Hippocratic oath. While some elements of the oath are out of date, this section in particular still has meaning.  There is a good reason why this oath is recited by most medical students upon their graduation. It evokes the core value of our profession. My concern is that if this question passes, this value will be undermined, and we may always regret the day that this happened.

Thank you, and I look forward to our discussion and your questions.

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