Category: Ethical Commentary

“Do or Refer” Doctors Are Not Allowed to Use Their Best Judgment for Individual Patients (No More Jeanette Halls)

Choice is an Illusion

Margaret Dore

Yesterday, a doctor asked me about “do or refer” provisions in some of the newer bills seeking to legalize assisted suicide in the United States. For this reason, I now address the subject in the context of a 2018 Wisconsin bill, which did not pass.

The bill, AB 216, required the patient’s attending physician to “fulfill the request for medication or refer,” i.e. to write a lethal prescription for the purpose of killing the patient, or to make an effective referral to another physician, who would do it.

The bill also said that the attending physician’s failure to comply would be “unprofessional conduct” such that the physician would be subject to discipline. The bill states:

[F]ailure of an attending physician to fulfill a request for medication [the lethal dose] constitutes unprofessional conduct if the attending physician refuses or fails to make a good faith attempt to transfer the requester’s care and treatment to another physician who will act as attending physician under this chapter and fulfill the request for medication. (Emphasis added).[1]

The significance of do or refer is that it’s anti-patient, by not allowing doctors to use their best judgment in individual cases.

Consider Oregonian Jeanette Hall. In 2000, she made a settled decision to use Oregon’s assisted suicide law in lieu of being treated for cancer. Her doctor, Kenneth Stevens, who opposed assisted suicide, thought that her chances with treatment were good. Over several weeks, he stalled her request for assisted suicide and finally convinced her to be treated for cancer.

Yes, Dr Stevens was against assisted suicide generally, but he also thought that Jeanette was a good candidate for treatment and indeed she was. She has been cancer free for 19 years. In a recent article, Jeanette states: 

I wanted to do our law and I wanted Dr. Stevens to help me. Instead, he encouraged me to not give up and ultimately I decided to fight the cancer. I had both chemotherapy and radiation. I am so happy to be alive!

If “do or refer,” as proposed in the Wisconsin bill, had been in effect in Oregon, Dr. Stevens would have been risking a finding of unprofessional conduct, and therefore his license, to help Jeanette understand what her true options were.

Is this what we want for our doctors, to have them be afraid of giving us their best judgment, for fear of sanction or having their licenses restricted or even revoked?  

With proposed mandatory “do or refer,” assisted suicide proponents show us their true nature. They don’t want to enhance our choices, they want to limit our access to information to railroad us to death.

Notes

[1] AB 216 states:

156.21 Duties and immunities. (1) No health care facility or health care provider may be charged with a crime, held civilly liable, or charged with unprofessional conduct for any of the following:  

(a) Failing to fulfill a request for medication, except that failure of an attending physician to fulfill a request for medication constitutes unprofessional conduct if the attending physician refuses or fails to make a good faith attempt to transfer the requester’s care and treatment to another physician who will act as attending physician under this chapter and fulfill the request for medication. (Emphasis added).

Margaret Dore is an attorney in Washington State where assisted suicide is legal. She is also president of Choice is an Illusion, a nonprofit corporation opposed to assisted suicide and euthanasia worldwide.

The caricature of the conscientiously objecting physician

Objecting doctors are the bad guys, obstructing care.

How will disciplining conscientious doctors or driving them from the profession improve health care?

Physicians’ Alliance Against Euthanasia

Catherine Ferrier

Weary physicianCanadian doctors who object to directly causing the death of their patients, once the near-totality of the profession, have since the enactment of laws permitting “medical assistance in dying” suddenly become outliers. Polling data is unclear, polls are often biased, and there is no doubt that the euthanasia lobby had the ear of media, opinion leaders and politicians long before we knew what they were up to. Be that as it may, we are now told that euthanasia/MAiD is an accepted ‘medical treatment’ that must be provided to those who request it. Many provincial medical colleges, though not requiring doctors to euthanize patients themselves, do expect, to different degrees, that we facilitate their being euthanized by someone else. . . [Full text]

Physician Participation in Lethal Injection

Deborah W. Denno

On April 1, 2019, the U.S. Supreme Court rejected a Missouri death-row inmate’s claim that executing him using the state’s lethal-injection protocol would violate the Eighth Amendment’s ban on “cruel and unusual punishment” because blood-filled tumors in his head, neck, and throat could rupture and cause him to choke and suffer “excruciating” and “prolonged pain.”. . . the opinion’s unusual facts and circumstances throw into sharp relief the pervasiveness of physician participation in lethal injection despite the medical community’s professed condemnation of such involvement. . .

Denno DW. Physician Participation in Lethal Injection. N Engl J Med 2019; 380:1790-1791 DOI: 10.1056/NEJMp1814786

Is there a difference between palliative sedation and euthanasia?

BioEdge

Xavier Symons

One common argument in favour of legalising euthanasia is that several accepted medical practices already involve hastening the death of patients. Some ethicists claim, for example, that we are already hastening patients’ deaths in palliative care contexts through the administration of toxic levels of opioids and sedatives to patients. In palliative sedation — a relatively common procedure in end of life scenarios — doctors administer strong doses of drugs such as midazolam to sedate a patient. Ostensibly this is done to relieve refractory symptoms, yet some suggest that doctors are fully aware that the drugs may bring about a quicker death. In light of this, some ethicists argue that we need not be so concerned about hastening death through euthanasia — this is a mere extension of the already existing practices in palliative care.

There are two common rejoinders to this argument. The first is that palliative sedation does not even hasten death — in fact, studies show that it actually may prolong life. Thus, there is no causal link between the administration of analgesics and barbiturates and the death of the patient.

The second is that the practice of palliative sedation is defensible on the basis of double effect reasoning. The doctrine of double effect is quite difficult to summarise in a sentence, but essentially the claim is that doctors do not intend for the patient’s death to be hastened, even though they foresee that this may be the case.

A new article in the Journal of Medical Ethics attempts to critique these two responses. Doctor Thomas David Riisfeldt of the University of New South Wales argues that empirical evidence on palliative sedation does not in fact provide a reliable indication of whether or not palliative sedation hastens death. In a blog post summarising the article, Riisfeldt writes:

“[the claim that pain killers and sedatives do not hasten death] is not watertight at all.  This is mainly owing to the ethical limitations (more so, the ethical impossibility) of conducting high-quality randomised controlled trials to definitively compare survival times in patients receiving or not receiving palliative opioids and sedatives, along with a number of other practical difficulties.  I conclude that adopting a position of agnosticism on the matter is appropriate”.

In the article, Riisfeldt also suggests that the doctrine of double effect is indefensible, and argues that — in the case of palliative sedation — there is no meaningful distinction between the direct effect of the action (pain relief) and the unintended consequence (death).

So, does Riisfeldt’s critique itself hold water? He makes a series of controversial claims regarding the nature of palliative sedation, and whether it violates the sanctity of life principle (he believes that it does). It seems to this author that his essay would be befitting a robust response from someone familiar with the literature on palliative sedation and also the across the ethics of double effect.

Is there a difference between palliative sedation and euthanasia?

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“Choose, You Lose” Scheme Threatens All Ethical Professionals

Jonathon Imbody

The increasingly aggressive discrimination in recent years against religious and pro-life healthcare professionals and students[1] parallels a concentrated effort by abortion proponents to undermine the rationale for conscience protections in healthcare. Desperate abortion advocates apparently have concluded that the way to counter the medical community’s resistance to abortion is through coercion.

Coercion appeals to some activists because coercion is much quicker than persuasion in effecting change. If abortion activists can eliminate conscience protections, then health professionals can be forced to participate in abortion or else sacrifice their careers. .

American principles protect conscience even at a price

Affordable Care Act architect Dr. Ezekiel Emanuel and University of Pennsylvania professor Ronit Stahl lay the foundation for getting rid of healthcare conscience protections, in a New England Journal of Medicine opinion piece entitled, “Physicians, Not Conscripts — Conscientious Objection in Health Care.”[2]

Their message is simple: Choice is a one-way street. Patients get to choose; doctors don’t—at least not after they enter the medical profession.

Emanuel and Stahl attempt to establish this radical principle by postulating a sharp distinction between conscience accommodations for military draftees and conscience accommodations for physicians.

Emanuel and Stahl write,

Although this [conscience healthcare protection] legislation ostensibly mimics that of military conscientious objection, it diverges considerably. Viewing conscientious objection in health care as analogous to conscientious objection to war mistakes choice for conscription, misconstrues the role of personal values in professional contexts, substitutes cost-free choices for penalized decisions, and cedes professional ethics to political decisions.”[3]

In the United States, a pacifist opposed to the military draft can receive a conscientious exemption from combat duty, even during a time of war when every other able-bodied citizen his age is expected to fight to defend the national interest. The cost to the country is high if counted in terms of fewer soldiers available for active duty.

Yet the authors would countenance no such rights, no such accommodation of cost, to a pro-life physician who cannot on the basis of conscience end the life of a developing baby in an elective abortion. While permitting the pacifist draftee a conscientious objection to killing, the authors contend, government must deny the same objection by a health professional.

Why? According to Emmanuel and Stahl, the reason is that physicians choose their professions, whereas draftees do not choose to join the military. . .[Full text]