Emotional Debate on "Physician Assisted Suicide"

On Tuesday night, November 26th, I drove to Houston to hear Wesley J. Smith, debate Physician Assisted Suicide (PAS) with Kathryn Tucker, the Director of Legal Services for Compassion & Choices, which was once the old Hemlock Society and then Compassion in Dying. Mr. Smith is the author of The Culture of Death and Forced Exit: Euthanasia, Assisted Suicide, and the New Duty to Die. The only biographical data I can find on Ms.Tucker is this pdf.

The Holocaust Museum Houston has teamed up with the University of Texas Health Science Center at Houston to present the Dr. Michael E. DeBakey Medical Ethics Lecture Series, called ""Medical Ethics and the Holocaust: How Healing Becomes Killing--Eugenics, Euthanasia and Extermination."

From the first, opening night, presentation featuring the-soon-to-be-unpopular James Watson and two other Nobel Laureates, it seems that we are being exposed to an ethics lab, rather than a history and theoretical series. The speakers the first night, including a doctor, Eric Kandel, M.D., 2000 Nobel Laureate, Medicine or Physiology, who was a child in Vienna on Krystallnacht before his family escaped to the US, told us not to worry about research on human embryos as long as the parents give "informed consent." Ironically, after descriptions of the build up to the Holocaust, Dr. Kandel reassured us that that we would gradually get accustomed to embryonic stem cell research.

I could tell that Mr. Smith and Ms. Tucker were irritated with each other during the program. In her introduction, Ms. Tucker referred to an earlier debate that had taken place that day when, as Wesley later told us, "it got angry." I got the idea that the moderator, Dr.Sheldon Rubenfeld, was slightly testy, although he did a good job moderating the questions, as always.

Ms. Tucker' s history of redefining, renaming, and litigating did not reassure me.

She was the lawyer in the case of a family suing a doctor for failing to give their loved one enough medicine to control pain at the end of his life and has fought laws against PAS for 10 years. Ms. Tucker misrepresented "terminal sedation," as though it is always intended to lead to death, rather than "deliberately inducing and maintaining deep sleep but not deliberately causing death in very specific circumstances." It was a surprise to hear Ms. Tucker warn against "back alley deaths" although it turns out that it wasn't the first time I'd heard the term. She frequently used the word, "choice," comparing the patient's choice at the end of life with a woman's right to "Reproductive Choice."

The silliest part of the evening - we were discussing death, after all - was when Ms. Tucker chided Mr. Smith for using the wrong terminology, "Physician Assisted Suicide." She showed us the recently revised policy statements of the American Medical Women's Association and the American Public Health Association. Because these two second tier (that's a word I learned from John Gearhart while attending the ASBH conference this year) organizations revised their own terminology to avoid the "emotionally charged" nature of certain words within the last year, Ms. Tucker shamed Mr. Smith for using the American Medical Association's terminology and legal term instead of calling the act "Aid in Dying."

Mr. Smith pointed more clearly to the problem of emotions when he remarked that it is often acknowledged in these debates that "existential pain," or the emotional component of pain, may be worse than physical pain.

No matter what we call it, death is always going to be an emotionally charged subject and is rarely dignified or controlled. For one thing, the body loses control of the bowels and bladder at death, as well as everything else. The questions from the audience were examples of people who approach the subject of end of life care from a strictly emotional viewpoint, rather than thinking it through to its logical consequences. The emotion is getting stronger as technology introduces more and more variables.

However, when we are discussing Medicine and the death of the body as well as of the mind and spirit, we should confine our conversations to the physical consequences. To be trite: When you're dead, you're dead.

There is no legal question as to whether "Assisting" or "Aiding" death is different from withdrawing care. We don't pinch the patient's nose or remove the oxygen from the room when we withhold or withdraw a ventilator. Physician Assisted Death, in contrast, is an irrevocable interventional act against the living processes of the body using State regulated medical knowledge and medicines, and should be treated as the violation of medical ethics that it is. The history of Western medicine, at least between Hippocrates and Roe, has always condemned intentional use of medicine to positively end the life of the body.

Mr. Smith and I have had several discussions about the ethics at the end of life, especially the Texas Advance Directive Act, which he refers to as the "Futile Care Act." We agree that doctors should never intend to cause death but that they may withhold or withdraw intervention at the request of the patient. We disagree, though, about whether a doctor may refuse to intervene because our best medical judgment is that the intervention will cause increasing damage to the body and prolong death.

I found myself, a Family Physician who cares for people at all stages of life, theoretically squeezed between two legal pressures, one law to force me to act with the purpose of killing a patient and another that would force me to act even though my medical judgment is that the intervention caused harm. Several people from the audience also advocated for legal consequences for doctors who failed to follow patients' end of life wishes by prolonging their lives.

To be honest, if I had to "choose" between the two, I would choose against Ms. Tucker's extreme, which would leave me with Mr. Smith's. I could live with that.

However, I hope that society will teach doctors to never take life while expecting the profession to assist one another in determining when medical intervention causes more bodily harm than healing, when a patient's bodily processes are breaking down faster than we can heal or maintain them.

(Edited 11/20/07 for grammar and order - BBN)