Saturday, November 3, 2012

Not All Opposition to Question 2 Is Slippery

I’m disappointed in Art Caplan.

The director of Medical Ethics at New York University is a go-to source for journalists and others needing clarity, opinions and insight into complex ethical questions in medicine. He also teaches and writes extensively on bioethics.

This week, Caplan endorsed passage of Question 2 in Massachusetts on the NBC News blog Vitals, But that isn’t what disappointed me.

Reading Caplan, I expected a serious counter-argument to strong and well considered pieces I’ve read recently by Lachlan Forrow and Ira Byock, both palliative physicians and ethicists, Forrow at Boston’s Beth Israel Deaconess Medical Center, Byock at Dartmouth.

Forrow takes no position for or against Question 2, the effort to legalize what is alternately known as death with dignity or physician-assisted suicide, but he makes a compelling case for why it should be decided by legislators, not voters. But Byock is clear in his opposition, and why.

Forrow and Byock are of such standing in medicine that Caplan must know of them, and their criticisms of Question 2. Closer to home for Caplan, Dr. Zeke Emanuel recently listed in the New York Times his own reasons for opposing the practice. 

And yet, according to Caplan, other than medical organizations opposed on grounds that Question 2 changes the physician’s traditional role as healer, the only opposition of note fits neatly into the category of slippery slopers.

“The critics are worrying about a shift to mass suicide inspired by heartless doctors and families pressuring dying patients to end it,” Caplan writes. “That has simply not happened in Oregon or Washington. There is no persuasive evidence that the dying are being rushed, duped or bullied to die by anyone.”

Perhaps this is an effective argument against slippery slopers, and it’s one that Forrow probably would agree with. He has written that with Washington and Oregon as predictors, neither defeat nor passage will have a major effect on care in Massachusetts.

And yet, “I have serious misgivings about whether a ballot initiative is the best way for the people of Massachusetts to make decisions about profound, complex  issues,” Forrow writes. “My misgivings are especially great when, as I believe is true of Question 2 next Tuesday, many people are going to have to cast their vote without having had the time, opportunity, or help they needed to develop a clear and accurate understanding of what those issues are.’’

Advocates for both sides are distorting the essential questions, Forrow writes, with “irresponsibly exaggerated claims that are designed to frighten you into voting one way or the other. If I didn't know better, I would be more frightened than ever about myself or a loved one ever having a so-called terminal illness.”

Forrow has a special interest in improving end-of-life care in Massachusetts. He was co-chair of the Expert Panel on End of Life Care, which has produced an extensive and impressive report for the governor. It details many ways the state could improve its care of the dying, none of which are expediting their death.

Many of the Expert Panel’s points would align with those made by Byock in the Atlantic in arguing why progressives ought not support Question 2.

Byock writes: “An authentic progressive agenda for improving the way we die would begin by tying physician and hospital payments to quality of care, not quantity of tests and treatments, and doubling the ratio of nurses and aides to residents in nursing homes. ... Also high on a liberal agenda should be repealing regulations that require sick people to give up life-prolonging treatments to receive hospice care. Finally, it's past time to insist that every medical student receives adequate training and passes competency tests in symptom management, communication and counseling related to serious illness and dying -- skills that most physicians lack today.”

Why not make lethal prescriptions part of this? “Giving doctors lethal authority,” Byock writes, “would address none of the deficiencies in medical practice, health care financing or social services that bring ill people to contemplate ending their lives.”

As an ordained minister, the former TV journalist Liz Walker might be forgiven a slippery slope argument, but her opposition is not of the slippery sort, either. Aspects of Question 2 that trouble Walker include the lack of a requirement that patients speak to a mental health specialist, a palliative specialist, or even tell their families.

“Patients could choose to end their lives without ever talking to a spouse or family member,” she writes. “Supporters of the initiative call it a ‘compassionate choice’ but leaving families in the dark and patients on their own on this profound matter strikes me as anything but compassionate.”

Some will vote for purely slippery-slope reasons, but some critics of Question 2 are on firmer footing, and Caplan ought to have acknowledged that. 


  1. Community Voice in Medical Ethics is very important because with the passage of the normal life and professions we need to work on these topics also or at least should give or share our words in superior paper. Because that's the only strategy in order to train the new generation and the current generation so that they will be able to manage manners and will work hard in order to spread them.