Ethical Issues in Medical Oncology: Physician Aid-in-Dying

Ethical Issues in Medical Ethical Issues in Medical Oncology: Physician Aid-in-DyingOncology: Physician Aid-in-Dying

Ethical Issues in Medical Ethical Issues in Medical Oncology: Physician Aid-in-DyingOncology: Physician Aid-in-Dying

ErnlErnléé W.D. Young Ph.D., Professor of W.D. Young Ph.D., Professor of Medicine Emeritus (Biomedical Ethics) Medicine Emeritus (Biomedical Ethics)

Stanford University School of MedicineStanford University School of Medicine

ErnlErnléé W.D. Young Ph.D., Professor of W.D. Young Ph.D., Professor of Medicine Emeritus (Biomedical Ethics) Medicine Emeritus (Biomedical Ethics)

Stanford University School of MedicineStanford University School of Medicine

OutlineOutlineOutlineOutline

1.1. Define Physician Aid-in-Dying (PAD) Define Physician Aid-in-Dying (PAD) 2.2. History of PADHistory of PAD3.3. Arguments Arguments AgainstAgainst PAD PAD4.4. Arguments Arguments in Favorin Favor of PAD of PAD5.5. Weighing the ArgumentsWeighing the Arguments6.6. Oregon’s Oregon’s Death With DignityDeath With Dignity Act Act7.7. Making up One’s Making up One’s OwnOwn Mind: Mind:

An Ethical Framework and Three CaseAn Ethical Framework and Three CaseScenarios for Small Group DiscussionScenarios for Small Group Discussion

1.1. Define Physician Aid-in-Dying (PAD) Define Physician Aid-in-Dying (PAD) 2.2. History of PADHistory of PAD3.3. Arguments Arguments AgainstAgainst PAD PAD4.4. Arguments Arguments in Favorin Favor of PAD of PAD5.5. Weighing the ArgumentsWeighing the Arguments6.6. Oregon’s Oregon’s Death With DignityDeath With Dignity Act Act7.7. Making up One’s Making up One’s OwnOwn Mind: Mind:

An Ethical Framework and Three CaseAn Ethical Framework and Three CaseScenarios for Small Group DiscussionScenarios for Small Group Discussion

What is Physician Aid-in-Dying?What is Physician Aid-in-Dying?What is Physician Aid-in-Dying?What is Physician Aid-in-Dying?

Modeled on Oregon’s Modeled on Oregon’s Death With Death With Dignity ActDignity Act

As Set Out in California’s AB 654As Set Out in California’s AB 654

A Process to Request Life-ending A Process to Request Life-ending MedicationMedication

Modeled on Oregon’s Modeled on Oregon’s Death With Death With Dignity ActDignity Act

As Set Out in California’s AB 654As Set Out in California’s AB 654

A Process to Request Life-ending A Process to Request Life-ending MedicationMedication

Oregon’s Death With Dignity ActOregon’s Death With Dignity ActOregon’s Death With Dignity ActOregon’s Death With Dignity Act

An Adult (18 Years of Age or Older)An Adult (18 Years of Age or Older)

A Resident of OregonA Resident of Oregon

Capable (Defined as Able to Make Capable (Defined as Able to Make and Communicate Health Care and Communicate Health Care Decisions)Decisions)

Diagnosed With a Terminal Illness Diagnosed With a Terminal Illness That Will Lead to Death Within Six That Will Lead to Death Within Six MonthsMonths

An Adult (18 Years of Age or Older)An Adult (18 Years of Age or Older)

A Resident of OregonA Resident of Oregon

Capable (Defined as Able to Make Capable (Defined as Able to Make and Communicate Health Care and Communicate Health Care Decisions)Decisions)

Diagnosed With a Terminal Illness Diagnosed With a Terminal Illness That Will Lead to Death Within Six That Will Lead to Death Within Six MonthsMonths

Requirements for Lethal MedicationRequirements for Lethal MedicationRequirements for Lethal MedicationRequirements for Lethal Medication

Two Oral RequestsTwo Oral RequestsA Written Request A Written Request A Confirmed Diagnosis & PrognosisA Confirmed Diagnosis & PrognosisPatient Must be CapablePatient Must be CapableIf Judgment is Impaired, the Patient If Judgment is Impaired, the Patient Must be ReferredMust be ReferredMust be Informed of AlternativesMust be Informed of AlternativesNotification of Next of KinNotification of Next of Kin

Two Oral RequestsTwo Oral RequestsA Written Request A Written Request A Confirmed Diagnosis & PrognosisA Confirmed Diagnosis & PrognosisPatient Must be CapablePatient Must be CapableIf Judgment is Impaired, the Patient If Judgment is Impaired, the Patient Must be ReferredMust be ReferredMust be Informed of AlternativesMust be Informed of AlternativesNotification of Next of KinNotification of Next of Kin

A Brief ChronologyA Brief ChronologyA Brief ChronologyA Brief Chronology

1991—Washington’s Proposition 119, Narrowly 1991—Washington’s Proposition 119, Narrowly DefeatedDefeated1992—California’s Proposition 162, Narrowly Defeated1992—California’s Proposition 162, Narrowly Defeated1994—Oregon’s Measure 16, Passed by 51/491994—Oregon’s Measure 16, Passed by 51/491996—91996—9thth and 2 and 2ndnd Circuits Courts of Appeal rule State Circuits Courts of Appeal rule State Prohibitions on P-A-D UnconstitutionalProhibitions on P-A-D Unconstitutional1997—The Supreme Court Reverses, But Leaves the 1997—The Supreme Court Reverses, But Leaves the Door OpenDoor Open1997—Oregon’s Measure 16 Reaffirmed by 60/401997—Oregon’s Measure 16 Reaffirmed by 60/401998—Measure 16 Becomes Law in Oregon1998—Measure 16 Becomes Law in Oregon2004—Ashcroft Moves to Criminalize the Prescription of 2004—Ashcroft Moves to Criminalize the Prescription of Medicine that “Will Result in Patients’ Deaths.”Medicine that “Will Result in Patients’ Deaths.”2005—Gonzales v. Oregon appealed to Supreme Court2005—Gonzales v. Oregon appealed to Supreme Court2005—California’s AB 654 now Moot2005—California’s AB 654 now Moot

1991—Washington’s Proposition 119, Narrowly 1991—Washington’s Proposition 119, Narrowly DefeatedDefeated1992—California’s Proposition 162, Narrowly Defeated1992—California’s Proposition 162, Narrowly Defeated1994—Oregon’s Measure 16, Passed by 51/491994—Oregon’s Measure 16, Passed by 51/491996—91996—9thth and 2 and 2ndnd Circuits Courts of Appeal rule State Circuits Courts of Appeal rule State Prohibitions on P-A-D UnconstitutionalProhibitions on P-A-D Unconstitutional1997—The Supreme Court Reverses, But Leaves the 1997—The Supreme Court Reverses, But Leaves the Door OpenDoor Open1997—Oregon’s Measure 16 Reaffirmed by 60/401997—Oregon’s Measure 16 Reaffirmed by 60/401998—Measure 16 Becomes Law in Oregon1998—Measure 16 Becomes Law in Oregon2004—Ashcroft Moves to Criminalize the Prescription of 2004—Ashcroft Moves to Criminalize the Prescription of Medicine that “Will Result in Patients’ Deaths.”Medicine that “Will Result in Patients’ Deaths.”2005—Gonzales v. Oregon appealed to Supreme Court2005—Gonzales v. Oregon appealed to Supreme Court2005—California’s AB 654 now Moot2005—California’s AB 654 now Moot

Arguments AGAINST PADArguments AGAINST PADArguments AGAINST PADArguments AGAINST PAD

ReligiousReligious

The CMAThe CMA

Many Palliative Care & Hospice ProvidersMany Palliative Care & Hospice Providers

The Lobby for the DisabledThe Lobby for the Disabled

ReligiousReligious

The CMAThe CMA

Many Palliative Care & Hospice ProvidersMany Palliative Care & Hospice Providers

The Lobby for the DisabledThe Lobby for the Disabled

Arguments IN FAVOR of PADArguments IN FAVOR of PADArguments IN FAVOR of PADArguments IN FAVOR of PAD

ReligiousReligious

Many Oncologists and NursesMany Oncologists and Nurses

Many PatientsMany Patients

Patients’ Advocacy GroupsPatients’ Advocacy Groups

ReligiousReligious

Many Oncologists and NursesMany Oncologists and Nurses

Many PatientsMany Patients

Patients’ Advocacy GroupsPatients’ Advocacy Groups

Weighing the ArgumentsWeighing the ArgumentsWeighing the ArgumentsWeighing the Arguments

Absolute Sanctity vs. Quality of LifeAbsolute Sanctity vs. Quality of Life

The Roman Catholic ProhibitionThe Roman Catholic Prohibition

The Biblical References to SuicideThe Biblical References to Suicide

The View of ModeratesThe View of Moderates

Absolute Sanctity vs. Quality of LifeAbsolute Sanctity vs. Quality of Life

The Roman Catholic ProhibitionThe Roman Catholic Prohibition

The Biblical References to SuicideThe Biblical References to Suicide

The View of ModeratesThe View of Moderates

1. The Religious Debate1. The Religious Debate1. The Religious Debate1. The Religious Debate


Beneficence andBeneficence and

NonmaleficenceNonmaleficence

Beneficence andBeneficence and

NonmaleficenceNonmaleficence

2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:

2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:2.Tension Between the Medical Mandate Not to Harm and Alleviating Suffering. Between the Ethical Principles of:


Pain is ManageablePain is Manageable

Not Possible to Relieve All PainNot Possible to Relieve All Pain

Difference Between Pain and SufferingDifference Between Pain and Suffering

Pain is ManageablePain is Manageable

Not Possible to Relieve All PainNot Possible to Relieve All Pain

Difference Between Pain and SufferingDifference Between Pain and Suffering

3. Dying Invested with Meaning3. Dying Invested with Meaning3. Dying Invested with Meaning3. Dying Invested with Meaning


The Simplified Form of this ArgumentThe Simplified Form of this Argument

The Fallacy, Slippage is Not AutomaticThe Fallacy, Slippage is Not Automatic

Oregon’s Record Speaks for ItselfOregon’s Record Speaks for Itself

There has not been any slippageThere has not been any slippage

The Simplified Form of this ArgumentThe Simplified Form of this Argument

The Fallacy, Slippage is Not AutomaticThe Fallacy, Slippage is Not Automatic

Oregon’s Record Speaks for ItselfOregon’s Record Speaks for Itself

There has not been any slippageThere has not been any slippage

4. The Slippery Slope Argument4. The Slippery Slope Argument4. The Slippery Slope Argument4. The Slippery Slope Argument

19981998 19991999 20002000 20012001 20022002 20032003 20042004

Number of Number of

Prescriptions WrittenPrescriptions Written2424 3333 3939 4444 5858 6868 6060

Number of PhysiciansNumber of Physicians

Writing PrescriptionsWriting Prescriptions4040

Number of Deaths from Number of Deaths from Ingesting MedicationsIngesting Medications 1616 2727 2727 2121 3838 4242 3737

Number Not IngestingNumber Not Ingesting

MedicationMedication88 66 1212 2323 2020 2626 2323

Ratio of PAS Deaths to Ratio of PAS Deaths to Every 10,000 Total DeathsEvery 10,000 Total Deaths 5.55.5 9.29.2 9.19.1 7.07.0 12.212.2 13.613.6 1212

---------No Figures Available-----------------No Figures Available--------

Oregon’s Oregon’s Death With Dignity ActDeath With Dignity Act: : Facts and CommentaryFacts and Commentary


Figures from the Seventh Annual Report on Oregon’s Figures from the Seventh Annual Report on Oregon’s DeathDeath With Dignity Act With Dignity ActFigures from the Seventh Annual Report on Oregon’s Figures from the Seventh Annual Report on Oregon’s DeathDeath With Dignity Act With Dignity Act



49% of PAD patients used secobarbital49% of PAD patients used secobarbital

50% used pentobarbital50% used pentobarbital

2% used either 2% used either secobarbital/amobarbital or secobarbital/amobarbital or secobarbital/morphinesecobarbital/morphine

49% of PAD patients used secobarbital49% of PAD patients used secobarbital

50% used pentobarbital50% used pentobarbital

2% used either 2% used either secobarbital/amobarbital or secobarbital/amobarbital or secobarbital/morphinesecobarbital/morphine

Since the Since the Death With Dignity ActDeath With Dignity Act was was Implemented:Implemented:

Since the Since the Death With Dignity ActDeath With Dignity Act was was Implemented:Implemented:



Decreased Ability to Participate in Decreased Ability to Participate in Activities that Make Life Enjoyable Activities that Make Life Enjoyable (92%)(92%)

Losing Autonomy (87%)Losing Autonomy (87%)

Loss of Dignity (78%)Loss of Dignity (78%)

Decreased Ability to Participate in Decreased Ability to Participate in Activities that Make Life Enjoyable Activities that Make Life Enjoyable (92%)(92%)

Losing Autonomy (87%)Losing Autonomy (87%)

Loss of Dignity (78%)Loss of Dignity (78%)

Most Frequently Reported Concerns:Most Frequently Reported Concerns: Most Frequently Reported Concerns:Most Frequently Reported Concerns:



Malignant Neoplasms (79%)Malignant Neoplasms (79%)

Lung and Bronchus (19%)Lung and Bronchus (19%)

Breast (9%)Breast (9%)

Pancreas (6%)Pancreas (6%)

Colon (6%) Colon (6%)

Other (36%)Other (36%)

Malignant Neoplasms (79%)Malignant Neoplasms (79%)

Lung and Bronchus (19%)Lung and Bronchus (19%)

Breast (9%)Breast (9%)

Pancreas (6%)Pancreas (6%)

Colon (6%) Colon (6%)

Other (36%)Other (36%)

Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from:



ALS (8%) ALS (8%)

Chronic Lower Respiratory (5%)Chronic Lower Respiratory (5%)

HIV/AIDS (2%)HIV/AIDS (2%)

ALS (8%) ALS (8%)

Chronic Lower Respiratory (5%)Chronic Lower Respiratory (5%)

HIV/AIDS (2%)HIV/AIDS (2%)

Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from: Patients Requesting PAD Suffered from:



Of Physicians Who Complied with Of Physicians Who Complied with Patient Requests for PAD:Patient Requests for PAD:

57% Practiced Family Medicine57% Practiced Family Medicine 22% Were Oncologists22% Were Oncologists 8% Were Internists8% Were Internists 70% Wrote Only a Single 70% Wrote Only a Single

PrescriptionPrescription



A Request for PAS Can: A Request for PAS Can: A Request for PAS Can: A Request for PAS Can:

Be an Opportunity to Explore Fears Be an Opportunity to Explore Fears and Wishes Around End-of-Life Careand Wishes Around End-of-Life Care

Make Patients Aware of Their OptionsMake Patients Aware of Their Options

Be an Opportunity to Explore Fears Be an Opportunity to Explore Fears and Wishes Around End-of-Life Careand Wishes Around End-of-Life Care

Make Patients Aware of Their OptionsMake Patients Aware of Their Options

An Ethical FrameworkAn Ethical FrameworkAn Ethical FrameworkAn Ethical Framework

Elements in Making Up One’s Own Mind: Elements in Making Up One’s Own Mind: Elements in Making Up One’s Own Mind: Elements in Making Up One’s Own Mind:

Acquire As Much Factual Information as Acquire As Much Factual Information as PossiblePossible

Identify Beliefs and ValuesIdentify Beliefs and Values

Apply the Principles of Biomedical EthicsApply the Principles of Biomedical Ethics

Factor in Data Extrinsic to the Clinical Factor in Data Extrinsic to the Clinical Situation, Such as the LawSituation, Such as the Law





Scenario 1Scenario 1Scenario 1Scenario 1

““Debra” had lived, fully and meaningfully, with chronic myelogenous Debra” had lived, fully and meaningfully, with chronic myelogenous leukemia for more than fifteen years. Then, unfortunately, her leukemia for more than fifteen years. Then, unfortunately, her remission ended. She had developed cellulitis secondary to the remission ended. She had developed cellulitis secondary to the chemotherapy that earlier had helped her. Gradually, circulation to her chemotherapy that earlier had helped her. Gradually, circulation to her extremities decreased, and her fingers and toes began turning blue, extremities decreased, and her fingers and toes began turning blue, then black, becoming gangrenous and causing exquisite pain. She then black, becoming gangrenous and causing exquisite pain. She was referred to Stanford’s pain clinic, where specialists in this field was referred to Stanford’s pain clinic, where specialists in this field tried everything they knew to give her relief, including nerve blocks. tried everything they knew to give her relief, including nerve blocks. Finally, all they could do was begin amputating her digits, one by one. Finally, all they could do was begin amputating her digits, one by one. This, in turn, exacerbated her pain because the wounds left by the This, in turn, exacerbated her pain because the wounds left by the amputations wouldn’t heal, and she still had “phantom pain”. She was amputations wouldn’t heal, and she still had “phantom pain”. She was in constant, unrelieved agony, when her oncologist (who was treating in constant, unrelieved agony, when her oncologist (who was treating her in her own home), prescribed sufficient sleeping pills for her to end her in her own home), prescribed sufficient sleeping pills for her to end her own life, giving her the tongue-in-cheek warning, “If you take more her own life, giving her the tongue-in-cheek warning, “If you take more than two of these at a time, that could kill you.” than two of these at a time, that could kill you.”

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Debra had the prescription filled, and kept the bottle of sleeping pills Debra had the prescription filled, and kept the bottle of sleeping pills on the night stand next to her bed. Her husband was willing to help on the night stand next to her bed. Her husband was willing to help her take them when she could no longer bear her pain. Fortunately, her take them when she could no longer bear her pain. Fortunately, that wasn’t necessary. Debra died quietly of her leukemia, still in pain, that wasn’t necessary. Debra died quietly of her leukemia, still in pain, without taking the overdose. without taking the overdose.

If Debra had been your patient, would or would you not have done for If Debra had been your patient, would or would you not have done for her what her oncologist did? her what her oncologist did?

Use the ethical framework to describe the reasons for your decision.Use the ethical framework to describe the reasons for your decision.

Page 2Page 2


A Vietnam veteran, who lost both his legs in that war, and who is not a A Vietnam veteran, who lost both his legs in that war, and who is not a churchgoer, is your patient. He now has end-stage laryngeal-churchgoer, is your patient. He now has end-stage laryngeal-esophageal carcinoma. Until recently, he was able to take small esophageal carcinoma. Until recently, he was able to take small amounts of liquid nourishment by mouth. Now it is apparent that, if he amounts of liquid nourishment by mouth. Now it is apparent that, if he is to survive, he needs artificial nutrition and hydration. He is opposed is to survive, he needs artificial nutrition and hydration. He is opposed to this, saying that he has nothing left to live for. to this, saying that he has nothing left to live for.

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His wife, a devout Roman Catholic, makes an appointment to see you, His wife, a devout Roman Catholic, makes an appointment to see you, says that she believes her husband is depressed, has been stock-says that she believes her husband is depressed, has been stock-piling the opiates you have been prescribing for his pain, and intends piling the opiates you have been prescribing for his pain, and intends to end his life with an overdose. She implores you to intervene, to end his life with an overdose. She implores you to intervene, because she considers suicide a mortal sin and cannot bear to think of because she considers suicide a mortal sin and cannot bear to think of life without him. life without him.

What, if anything, do you do?What, if anything, do you do?

Use the ethical framework to explain your answer. Use the ethical framework to explain your answer.

In arriving at your decision, what weight, if any, do you give to the In arriving at your decision, what weight, if any, do you give to the concerns of the lobbyists for the disabled?concerns of the lobbyists for the disabled?

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A 51-year old senior United Airlines flight attendant (who had flown A 51-year old senior United Airlines flight attendant (who had flown international routes for most of her career) has been admitted to the international routes for most of her career) has been admitted to the hospital with end-stage ovarian cancer. She is single, and had been hospital with end-stage ovarian cancer. She is single, and had been an extraordinarily beautiful woman, taking much pride in her an extraordinarily beautiful woman, taking much pride in her appearance. Now she cannot bear to see her beauty being ravaged appearance. Now she cannot bear to see her beauty being ravaged by her disease, nor does she want her colleagues, many of whom are by her disease, nor does she want her colleagues, many of whom are flying in to visit her literally from all over the world, to see her in her flying in to visit her literally from all over the world, to see her in her present condition. present condition.

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You are her oncologist. She asks you to provide her with conscious You are her oncologist. She asks you to provide her with conscious sedation, that is, to keep her below the level of consciousness while sedation, that is, to keep her below the level of consciousness while she gradually dies without natural or artificial hydration or nutrition. she gradually dies without natural or artificial hydration or nutrition.

Is your patient asking for physician aid-in-dying, or not? Why do you Is your patient asking for physician aid-in-dying, or not? Why do you think this? think this?

How would you use the ethical framework to respond to her request?How would you use the ethical framework to respond to her request?

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Apply the Ethical FrameworkApply the Ethical FrameworkApply the Ethical FrameworkApply the Ethical Framework









Ethical Issues in Medical Oncology: Physician Aid-in-Dying

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