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The Assisted-Suicide Debate
By Steve Gordon Ira Byock believes legalizing assisted suicide would not address the major problems that exist in caring for the dying.
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From his small office in the newest part of the Dartmouth-Hitchcock Medical Center, Ira Byock hopes to bring about something of a revolution. He wants to dramatically improve the care provided to people who are very old or very sick and dying.
Byock, director of palliative medicine at DHMC, has been at the medical center for just over a year. He said he went there because the institution had well-respected programs intended to improve the patient experience with disease and health care, such as the Center for Shared Decision Making, and because its leaders promised support for his vision of improving palliative care. That vision, he said in an interview last week, is to bring the principles of good palliative care -- effective pain management, for instance, and support for patients and families that goes beyond diagnosis and treatment -- to virtually all aspects of medical care.
“I think it's realistic to hope for a future in which nobody has to die alone and nobody has to die with their pain untreated,” he wrote in his 1997 book Dying Well: Peace and Possibilities at the End of Life.
What is needed to make that happen, among other changes, is better physician education, and more active support from the individuals and institutions in patients' communities, Byock said.
What is not needed, in his opinion, is a law legalizing physician-assisted suicide, such as the one that will be discussed by the Vermont Legislature this winter. It is based on one that has been in place in Oregon since 1997, and would allow a doctor to prescribe a lethal dose of a drug to a dying patient who requests it and who meets several criteria.
Byock, 53, of Grantham, is the long-time director of Promoting Excellence in End of Life Care, a program of the Robert Wood Johnson Foundation. He said he will avoid being an active opponent of the Vermont bill, which he thinks is misguided, but has a challenge for those who support it. He has a separate challenge for some of those who oppose the law.
What follows is an edited transcript of an interview with Byock in his DHMC office last week.
Ira Byock: If we were to legalize physician-assisted suicide in Vermont or New Hampshire or anywhere, tomorrow, the next day we would still have problems of medical education which would remain inadequate; with the treatment of pain, which would remain inadequate; with the use of advance directives, which would remain inadequate; with the lack of community support, … with the incredible short-staffing in our nursing homes and home health.
I used to be an ardent combatant for the con side, for the opposed side of the physician-assisted suicide debate. My stance now is that both sides are wrong. To the people who are promoting physician-assisted suicide, what I want to know is, what are you going to do after you win? Are you going to help us to work on the bedrock issue that there're not enough nurse's aides in our nursing homes to help people who want to eat but can’t? Or are you going to perhaps work to expand the assisted-suicide law so that people who are unable to take the pills themselves can still make use of this “hastened death”? I think we are deluding ourselves by thinking that this is the main issue that we need to discuss.
Valley News: What do you say to the other side?
IB: I'll tell you, the religious groups that have opposed (it), and the right-to-life groups, should be ashamed of themselves. Because they have only told us what they're against. And I'm sorry, but that’s a half a stance. They’ve yet to tell us or to show us what they’re really for. In addition to being against physician-assisted suicide, where are you when studies are published that show that elderly nursing home residents are starving because there are not enough nurse's aides to help them eat? Where are you when the (federal) DEA cracks down on the adequate treatment of pain, the adequate prescribing of pain medications?
VN: You mean making it harder to take care of people's pain?
IB: Right. Where are you on these bedrock issues about how we care for people? They have been remarkably silent in telling us what they're for, and more importantly, in developing programs to show us what enlightened volunteer and community support looks like for the people who, absent that support, look at their future and see only suffering or suicide. If that's the Sophie’s choice that people are presented with, then the choice of a seriously ill person to end their life might be entirely rational. But if so, I would submit, it's all the more tragic.
VN: You described the physician-assisted suicide debate recently as a distraction. The point you seem to be making is that it is a distraction from the more important discussions that should be taking place. But is there room for both? Let's say that the people who are in favor of physician-assisted suicide had an answer for your question -- What are you going to do the next day? -- and your ideal for improving the choices were really (carried out). You would still have people who were close to death, and in great pain that was hard to manage …
IB: So are we having an abstract conversation now? Are we having a philosophical conversation? Because, in fact, I don't know how many people there would be.
VN: I'm just wondering whether even in your vision of a better world for people facing serious illness and death, there might still be room for somebody to decide, I just don't want to go through the next two weeks or whatever it might be of intense pain. I'd like to end my life earlier. Is there potentially room for that?
IB: I think that's a question that voters and society need to decide. I have other priorities to work on rather than that. And I believe that physicians will continue to have more than enough challenges in taking really good care of patients to stay focused there.
I think suicide and physician-assisted suicide are two very different things. I am not going to institute a psychiatric hold on somebody with far advanced illness who has hoarded pills and decides to end their life. But I don't think it's the role of a physician, certainly not my role, to assist them in pre-empting death.
In fact, most people who come to me and say (they are) interested in having lethal prescriptions are currently taking medications to prolong their life, and have lots of ways that they could end their life without my help. What they're asking for is my almost priestly blessing that they are as helpless and hopeless as they feel. And in fact, therapeutically, I believe my role is to help them to discover some hope and some sense of value in whatever life is remaining.
VN: Whether it's months, weeks, days or hours.
IB: Exactly. Yes. Now, you said, well, they don't want to go through the last two weeks of life. Well, you know, the Oregon law won't help you in that situation. The bill that’s going to be introduced in Vermont wouldn't help in that situation, because there’s a two-week waiting period between the two (doctor) visits. But many people who want to do that could die more quickly simply by stopping the medications they're currently taking and perhaps by not forcing themselves to eat when they’re not hungry and drink when they’re not thirsty. They already have the control that they’re seeking. It’s not the right issue.
VN: If you could pull the Vermont law that's being discussed now right off the table, and replace it with your idea of what would be a better thing for a state government to do, is there anything that comes to mind?
IB: I hope to be active in the discussion in Vermont. I am going to avoid being an opponent of the physician-assisted suicide law. What I would like to challenge its supporters to do -- as well as the medical profession in Vermont, the legislature, the governor -- is to also introduce a bill that would require at least 100 hours of medical training related to components of palliative care within the required education of every medical student trained in Vermont as a condition for graduating from medical school.
We currently require 170 to 200 hours of obstetrics training for every medical student prior to graduation, and yet very few students ever go on to deliver babies in practice, and every single one who does has taken a separate post-graduate residency in obstetrics or in family practice. The majority of physicians, whatever their discipline, end up helping to care for people through the last year of their lives.
Secondly, I think that bill should require that the state board of medical examiners test and certify that each physician demonstrate basic skills and knowledge of pain assessment and management as a condition for receiving or renewing a medical license. Because these are core skills of medicine. The fact that we are not teaching them and that demonstrably many physicians in practice don't have these basic skills is not OK. It would be as if the FAA were saying pilots have to take off and fly, but being able to land is optional.
I think the proposals to legalize assisted-suicide, from my perspective, would be better constructed if they left the role of the physician solely in certifying that a patient has a qualifying condition. And otherwise left medicine out of the process. If a law were to be passed in this regard, the physician, just like we do with any number of other things, would say, yes, Joe has advanced cancer, or yes, Joe has far advanced congestive heart failure, or ALS or whatever. And then, under whatever the proposed law would be, Joe, having that certification, and having met any other requirements, could go to the pharmacy and get the medicine without a prescription. The authority came from the legislature to the patient.
VN: So if you as a physician certified that I was terminally ill, I could, with the authority of the legislature, get a lethal dose of something from a pharmacy.
IB: These are, after all, one-size-fits-all prescriptions. You don't need a physician's prescribing expertise to do this.
My worry is that when you legalize something like this, it becomes routinized. And then, a lot of different types of suffering will look like they fit into this category. I think as a culture, and I can certainly say as a medical culture, we are not mature enough to be given authority to end people's life by intention. It's like giving a 3-year-old a hammer. The entire world starts to look like a nail.
There are a lot of types of suffering that we physicians address which are very difficult to control and help people with. And we struggle with the people. That is the root of the word compassion, to suffer with. And I submit that if we begin as a society and culture to make pre-empting death seem wholesome, we will find that it is a solution to many problems that we encounter every day. That's why, speaking as a physician, somebody who is proud to be a physician, I don't think it’s a good thing for us to go down this path. And if society is hell-bent to legalize assisted suicide, then I hope the legislature gives that authority to somebody else.
“Valley News” health writer Steve Gordon can be reached by e-mail at sgordon@vnews.com.
The Assisted-Suicide Debate
By Steve Gordon
Valley News Staff Writer
February 4th, 2005
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